Public health workers lack guidance for solving ethical dilemmas

April 9, 2009
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ANN ARBOR—If avian flu breaks out, how do public health officials decide who gets the antiviral medication? Should a clinic dentist extract the tooth of a patient if it’s salvageable but the restoration isn’t covered by Medicaid?

Public health workers face ethical dilemmas in their everyday work and without a systemized plan or framework for decision-making, workers must make gut-wrenching decisions that often mean deciding between the haves and have-nots, says Nancy Baum, a Ph.D. candidate at the University of Michigan School of Public Health.

The study concluded that tailored decision-making guides that are tested on real-life situations may have great benefit in helping public health practitioners grapple with perplexing issues.

“We know a lot about ethical challenges in medicine, but not as much in the realm of public health,” Baum said. “But ethical challenges are not just limited to individual doctor patient relationships. They also exist at the community health and population health level.”

Baum and U-M colleagues Peter Jacobson and Susan Goold and Sara Gollust of the University of Pennsylvania identified five broad categories of ethical issues practitioners face: determining appropriate use of public health authority; resource allocation; political interference; ensuring standards on quality of care; and questioning the role of public health.

Yet, public health workers don’t receive much—if any—formalized training in this area. Nor do they have a systemized ‘oath’ for guidance similar to what physicians have.

The researchers interviewed 45 public health workers in various occupations in 13 Michigan health departments to determine the ethical challenges workers face and how they solve those problems.

They found that practitioners invoked a wide range of values in addition to those typically associated with public health, such as social justice, to respond to ethical challenges. They did not often use frameworks for decision-making, but rather conferred with colleagues or depended on their own moral upbringing.

The field of public health ethics is relatively new. In 2002, the Public Health Leadership Society developed a code of ethics, but it’s unclear how that’s being applied or whether most practitioners even know it exists, Baum says.

“Doctors and patients have been guided by research and writing about bioethics for 30 to 40 years. Entire organizations exist to study bioethics,” she said. “There might be some real benefit to developing frameworks to structure some of these decision-making processes in public health.”

Baum is a doctoral candidate in the Department of Health Management and Policy at the U-M School of Public Health. Jacobson is a U-M public health professor and principal investigator of the study, Goold is an associate professor in the Department of Internal Medicine and Bioethics Program, and Gollust is a Robert Wood Johnson Health & Society Scholar at the University of Pennsylvania.

For more information on the Department of Health Management and Policy at U-M’s School of Public Health: www.sph.umich.edu/hmp.

The University of Michigan School of Public Health (www.sph.umich.edu) has been promoting health and preventing disease since 1941, and is consistently ranked among the top five public health schools in the nation. Whether making new discoveries in the lab or researching and educating in the field, SPH faculty, students and alumni are deployed around the globe to promote and protect our health.

The University of Michigan School of Public Health (www.sph.umich.edu) has been promoting health and preventing disease since 1941, and is consistently ranked among the top five public health schools in the nation. Whether making new discoveries in the lab or researching and educating in the field, SPH faculty, students and alumni are deployed around the globe to promote and protect our health.