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1 Office of Scientific Integrity, Office of the Associate Director for Science, Office of the Director, Centers for Disease Control and Prevention, Atlanta, GA, USA
2 Regional Program on Bioethics, Office of Knowledge Management, Bioethics, and Research, Pan American Health Organization, Washington, DC, USA
3 Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
4 Center for Values, Ethics and the Law in Medicine, Sydney School of Public Health, The University of Sydney, Sydney, Australia
5 Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
6 Global Health Ethics, Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland

Book Affiliations

1 Centers for Disease Control and Prevention, Atlanta, Georgia, USA
2 Centers fo Disease Control and Prevention, Atlanta, Georgia, USA
3 Center for Values, Ethics and the Law in Medicine, Sydney School of Public Health, The University of Sydney, Sydney, Australia
4 Pan American Health Organization, Washington DC, District of Columbia, USA
5 Global Health Ethics, Department of Information, Evidence and Research, World Health Organization, Geneve, Switzerland
6 Division of STD Prevention National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
PMID: 28590692
Bookshelf ID: NBK435780
DOI: 10.1007/978-3-319-23847-0_1

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Introducing public health ethics poses two special challenges. First, it is a relatively new field that combines public health and practical ethics. Its unfamiliarity requires considerable explanation, yet its scope and emergent qualities make delineation difficult. Moreover, while the early development of public health ethics occurred in a western context, its reach, like public health itself, has become global. A second challenge, then, is to articulate an approach specific enough to provide clear guidance yet sufficiently flexible and encompassing to adapt to global contexts. Broadly speaking, public health ethics helps guide practical decisions affecting population or community health based on scientific evidence and in accordance with accepted values and standards of right and wrong. In these ways, public health ethics builds on its parent disciplines of public health and ethics. This dual inheritance plays out in the definition the U.S. Centers for Disease Control and Prevention (CDC) offers of public health ethics: “A systematic process to clarify, prioritize, and justify possible courses of public health action based on ethical principles, values and beliefs of stakeholders, and scientific and other information” (CDC 2011). Public health ethics shares with other fields of practical and professional ethics both the general theories of ethics and a common store of ethical principles, values, and beliefs. It differs from these other fields largely in the nature of challenges that public health officials typically encounter and in the ethical frameworks it employs to address these challenges. Frameworks provide methodical approaches or procedures that tailor general ethical theories, principles, values, and beliefs to the specific ethical challenges that arise in a particular field. Although no framework is definitive, many are useful, and some are especially effective in particular contexts. This chapter will conclude by setting forth a straightforward, stepwise ethics framework that provides a tool for analyzing the cases in this volume and, more importantly, one that public health practitioners have found useful in a range of contexts. For a public health practitioner, knowing how to employ an ethics framework to address a range of ethical challenges in public health—a know-how that depends on practice—is the ultimate take-home message.

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1.1. Introduction
1.2. Public Health
1.3. Ethics
1.4. Public Health Ethics
1.5. Ethical Frameworks
1.6. A Three-Step Approach to Public Health Decision Making

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Published: 07 October 2014

Teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes

Peter Schröder-Bäck 1 , 2 ,
Peter Duncan 3 ,
William Sherlaw 4 ,
Caroline Brall 1 &
Katarzyna Czabanowska 1 , 5

BMC Medical Ethics volume 15 , Article number: 73 ( 2014 ) Cite this article

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Teaching ethics in public health programmes is not routine everywhere – at least not in most schools of public health in the European region. Yet empirical evidence shows that schools of public health are more and more interested in the integration of ethics in their curricula, since public health professionals often have to face difficult ethical decisions.

The authors have developed and practiced an approach to how ethics can be taught even in crowded curricula, requiring five to eight hours of teaching and learning contact time. In this way, if programme curricula do not allow more time for ethics, students of public health can at least be sensitised to ethics and ethical argumentation. This approach – focusing on the application of seven mid-level principles to cases (non-maleficence, beneficence, health maximisation, efficiency, respect for autonomy, justice, proportionality) – is presented in this paper. Easy to use ‘tools’ applying ethics to public health are presented.

The crowded nature of the public health curriculum, and the nature of students participating in it, required us to devise and develop a short course, and to use techniques that were likely to provide a relatively efficient introduction to the processes, content and methods involved in the field of ethics.

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The context for teaching ethics in public health

Our purpose in this paper is to explain and discuss a framework for a university-based short course in public health ethics. The framework has been developed and employed now in several European universities and schools of public health, including the Ecole des hautes études en santé publique (France), Maastricht University (the Netherlands), and Bielefeld University (Germany). We begin by discussing some aspects of the context for teaching public health ethics that were important in our deliberations on why and how to engage in such teaching: and which formed fundamental starting points in the development of our framework. We then move on to explain and elucidate the mid-level ethical principles that form the content cornerstone of the framework; and the educational approach that it attempts to model. Crucially, we are not setting out simply to offer a description of what we have done but instead to analyse, discuss and ultimately attempt to justify both content and educational approach.

Public health professionals are frequently called upon in their daily practice to make both explicit and implicit choices that extend beyond the objective and practical and into the contested and ethical [ 1 ]. Balancing and coming to conclusions about the rights and duties of individuals, communities, populations and governments with regard to protecting and maintaining health is in many ways the central, deeply complex task of public health work [ 2 ]. Yet at the same time, evidence strongly suggests that public health professionals often receive little training and guidance on how to reach decisions informed by careful ethical thinking and become confident in a moral sense about the ‘trade-offs’ they are frequently required to make in practice [ 1 , 3 ].

Often facing difficult decisions without adequate training and preparation in an ethical sense is, therefore, a feature of the public health context that motivated us to think carefully about addressing this subject through teaching and learning. We were well aware of the pressures contributing to this state of affairs. These included the already crowded nature of the public health university curriculum and the difficulty of simply employing dominant conceptions of ‘medical ethics’ to a field with (at least in many respects) quite different concerns and priorities [ 4 ]. Moreover, knowledge about, and evaluation of, ethics education in teaching and learning about public health (in contrast to ethics in medical education) remains comparatively scarce [ 3 , 5 ].

Given these contextual issues, we were faced with an important set of questions: on what sorts of foundations should teaching and learning about public health ethics be based? How should teaching and learning in this field be enacted? What are the justifications for particular educational approaches? How can hard-pressed practitioners be sensitised to the idea that ethics permeates everything they do and that ultimately their enterprise is a moral one?

Content foundations for teaching and learning in public health ethics: the choice of mid-level principles

Teaching and learning in public health ethics involves making choices about what to teach, as well as how to teach it. The brief description and discussion of context that we have so far engaged in leads us towards beginning to describe and discuss our choices in relation to what we actually teach about.

The starting point for our discussion about the content of public health teaching is our belief that those engaged in it (both as teachers and learners) need to discriminate between and evaluate a complex range of normative judgments. Those who are working in public health are rarely doing so without having taken up normative positions on the purpose of the enterprise and the nature of its particular interventions and activities. They are operating with certain beliefs about, for example, the kind of society that public health should be aiming to reproduce [ 6 ] or about the sorts of ways in which individuals, communities or populations should lead their lives [ 7 ]. So an important outcome of teaching and learning in public health ethics is the capacity to make reasoned evaluations of the range of normative beliefs and values at work in the field.

As a discipline, ethics is also itself (at least in part) normative. It is about identifying and attempting to agree the importance of particular values (or kinds of values) [ 8 ]: and how and why separate values might influence decisions and choices about action. So those involved in teaching public health ethics have a further task of evaluation and discrimination: between the competing normative systems and judgments of moral philosophers themselves.

In fact, the tasks of evaluating normative beliefs within public health on the one hand, and normative judgments made by philosophers on the other, are complementary, indeed intertwined. The foundations of value-based decisions in public health (as with the broader field of health care and medicine more generally) lie in moral philosophical conceptions of what is valuable [ 9 ]. This leads us to the view that our framework for public health ethics teaching and learning should be based on a set of mid-level ethical principles, and critical appraisal and evaluation of these principles.

What do we mean by mid-level principles and why have we chosen them to form the central content of our framework? Such principles represent normative thinking that might stem from more than one moral philosophical theory and thus can be connected back to several theories. They are at the mid-point of a hierarchy that at its top is formed of overarching theories that attempt to explain and justify particular normative positions (for example, deontology and the pre-eminence of duty in moral consideration, or theories that focus on the importance of consequences in ethical deliberation); and at its bottom comprises a range of particular rules (expressed, say, through devices such as codes of conduct).

We argue here that because the principles are mid-level, and hold connections both with a number of normative theories and with the multiple prescriptions of codes and guidelines, they therefore garner wide acceptance [ 9 ]. The importance of individual principles such as we are advocating is also demonstrated by their being reflected in significant parts of the bioethics and public health ethics literature [ 9 – 13 ]. Thus the selection of these principles finds support and reflects positive experience in practice, as one of the authors of this current paper has established in previous work [ 14 ]. Equally, such principles may not command complete acceptance and can be challenged [ 15 ], making them highly useful in terms of encouragement for reflection and debate.

This combination of acceptability on the one hand and the potential for helpful challenge on the other provides justification for our choice of such principles. Given the major task of ‘squeezing ethics in’ to the crowded public health curriculum, employing them to provide the content foundation of our course framework allowed the opportunity for fairly swift appreciation of their relevance in the short time that we had available; while also proposing them as stimulators of more lengthy reflection, possibly undertaken outside and beyond formal class hours. Our choice aligns with the deliberations of the seminal Belmont Report:

‘[R]ules often are inadequate to cover complex situations; at times they come into conflict, and they are frequently difficult to interpret or apply. Broader ethical principles will provide a basis on which specific rules may be formulated, criticised and interpreted’ [ 16 ].

This justification of the use of mid-level principles as the content foundation of our teaching, and their location in a hierarchy of normative ethical theorising and judgment, leads us briefly to describing and discussing the principles themselves. Because of their place in the hierarchy, we need to note that an important anticipated outcome of our teaching and learning will be that students should be able to link the principles to overarching theories that exist ‘above’ them. Our particular concern is to encourage students towards recognising, understanding and critically appraising the principles’ connections to consequentialist theories (the value of an action lies in the good or bad consequences that it produces) such as utilitarianism; and deontology (the worth of an action lies prior to any consideration of its particular consequences and instead on its performance as a duty ).

We follow Beauchamp and Childress [ 9 ] not only in their account of mid-level principles but also as conceiving of them as being prima facie : each of equal weight at the outset of moral deliberation. Naturally, during the course of such deliberation, it is both possible and likely that a particular principle or principles will assume more or less importance. Thus the prima facie status of the principles, in our view, supports the process of careful ethical deliberation and reflection; answers are not ready made from the outset and choices have to be formulated.

There are seven principles that form the content grounds of our teaching framework:

Non-maleficence

The principle of non-maleficence – do no harm – asserts that a health care professional should act in such a way that he or she does no harm, even if her or his patient or client requests this [ 9 ]. This principle is the first to be proposed because of its historical antecedence; it is related to the famous Hippocratic ‘ primum nil nocere ’– first of all, do no harm’ of medical ethics, although not identical to it [ 9 , 17 , 18 ]. Within public health policy and practice, there are often occasions where degrees of harm are ‘traded off’ against the possibilities of greater harms, or perhaps positive benefit: for example, banning smoking in public places may cause harm to individual smokers but will prevent greater harms (and arguably produce benefit) through acting as a general disincentive to smoking among the wider population. Consideration of the non-maleficence principle shifts – at least – the burden of proof to those exercising potentially harmful behaviour that they are justified in doing so.

Beneficence

The obligation to produce benefit, for individual patients or clients, as we have implied above, is intimately connected to non- maleficence. Its apparently self- evident importance marks it out as the other core principle within the Hippocratic tradition: physicians should heal and help their patients, according to the physician’s abilities and judgment [ 19 ]. The distinctive difference between the principle of non-maleficence on the one hand and that of beneficence on the other lies in the fact that the former frequently – but not always – involves the omission of harmful action and the latter active contribution towards the welfare of others [ 9 ].

Health maximisation

Non-maleficence and beneficence can be understood in both deontological and consequentialist terms. Yet as principles they do not seem to go to the core of public health values. This is at least partly because of their tendency to be associated with, and used in trying to analyse, individual professional-client encounters. Even when following beneficence and non-maleficence in these individual encounters, it does not necessarily mean that population health is maximised, as the population is not at all within the focus of these micro- encounters. In the field of public health, the primary end sought is the health of the broader constituency of the public and improvements to this are the key outcome used to measure success [ 10 ]. In fact, the maximisation of population health, on the one hand, and beneficence and non-maleficence, on the other hand, can come into conflict.

One way of conceiving of the moral impulse of beneficence in public health terms is therefore to understand the ethical imperative to produce benefit in a wider sense and to talk of the obligation to ‘social beneficence’. Here we are thinking of the idea that public health professionals have an obligation to maximise health in the populations for which they are responsible. In fact, our preference is for the ethical principle underscoring this obligation to be referred to as one of health maximisation. This is because we need to be more specific than simply saying public health professionals have a duty to produce benefit (implied by the idea of ‘social beneficence’). What constitutes benefit (at both individual but especially at population level) is subject to dispute and may not necessarily be understood as ‘health’. It seems perverse to claim that public health professionals are primarily interested in other kinds of benefit over and above maximising health and opportunities for health; thus a specific principle of health maximisation, we argue, needs to constitute the third of the mid-level principles that form the content grounds of our short course teaching and learning. Of course, none of this is to deny the disputability of the concept of health, and the possibility of profound disagreement about what exactly it is that we are attempting to maximise [ 20 ]. There is a strong requirement to focus on maximising (population) health rather than on wider concepts of the “(common) good” (whatever is understood by this), which might well be outside the scope of public health. We will return to this point later in our discussion.

There will always be more health need than resources to deal with that need. Literally all public health systems (and health care systems) worldwide lack resources. These two statements prompt the advocacy of a moral duty to use scarce health resources efficiently. This duty exists at least partly because efficient use will enable public health professionals to produce more health benefit for greater numbers of people. So a moral principle of efficiency would demand, for example, the use of the evidence base and the performance of cost-benefit analyses to decide what should be done and how to do it.

As with the problematic of agreeing on the exact nature of the ‘health’ that we are supposed to be maximising in the previous principle, however, there is an equal difficulty here. ‘Efficiency’, along with associated notions such as ‘cost’ and ‘benefit’ are complex matters. For example, in considering the cost and benefit of undertaking (or not undertaking) a particular public health intervention, are we limiting our views of these things simply to the health sector or to the effect of the intervention on the wider social fabric and governance of public services? Moreover, it is conceivable to imagine limited or no action in the public health field as constituting ‘efficiency’ in the sense of negligible resource input yielding negligible returns but the cost-benefit ratio appearing reasonable in solely economic terms. Here we need to emphasise that the principle of efficiency has moral applicability, which needs to be disentangled from other considerations of efficiency, such as economics. (Efficiency is frequently linked to notions of ‘effectiveness’. We chose not to include ‘effectiveness’ as an explicit principle because it is somewhat implicit in the principle of health maximisation, and the strong sense this particular principle conveys that ethical public health action should naturally entail improvement in population health).

Respect for autonomy

The paternalistic benevolence contained in the principles of non-maleficence and beneficence is strongly tempered by the emphasis on respect for the autonomy of the patient who the health care professional is seeking to serve [ 9 , 21 ]. The principle of respect for autonomy extends, however, beyond the confines of individual health care; it is crucially important within the public health context. The frequent focus of public health on benefit for populations holds the potential for concern with individual welfare to be side- lined. Embedding respect for autonomy firmly within public health ethics teaching and learning provides a fundamental reminder that every person has a high value – qua her or his autonomy – and cannot merely be treated as a means to the end of others’ good. Despite this, however, the tension between individual rights and broader conceptions of public benefit is a profound one for public health as a field of practice. This tension, and the relative command that such broader conceptions of benefit often seem to possess, leads us to assert that in cases where autonomy restriction for wider public health goals is being contemplated (e.g. legislation banning smoking in public places or limiting movement during periods of contagion), the burden of proof for doing so needs always to lie with those advocating restriction.

It is equally possible to conceive of the principle of justice (sometimes ‘social justice’) as having grounds in the fundamental value of human autonomy. Because as humans we all have (or should have) autonomy, we all have (or should have) equal moral worth. Thus, proposals for the unequal treatment of people again require the burden of proof. Justice, to the contrary, demands equal opportunities. This also includes a fair distribution of health outcomes in societies, which is often discussed in terms of public health as ‘health equity’. In a very prominent conception of justice in the context of health, Daniels [ 13 ] considers health equity thus a matter of fairness and justice. Under Daniels’ conception of justice, health inequalities are unfair and unjust – and thus in conflict with health equity – if the socially controllable factors that lead to health are not distributed in such a way that the health of all citizens is protected or restored as much as possible.

Given the essential importance of health in the formation and development of every aspect of our equally valuable human lives – what Boorse [ 22 ] describes as ‘species typical functioning’ – we owe each other equal access to health goods and positive determinants of health [ 13 ]. Justice is also the principle that covers normative aspects that are often discussed in the terminology of solidarity and reciprocity. Justice does so by giving an answer to the question of what we owe to each other [ 13 ]. To have a concise set of principles, we focus only on justice.

Proportionality

Our seventh and final principle differs somewhat from those preceding it. As a principle, proportionality is certainly normative. It demands that in weighing and balancing individual freedom against wider social goods, considerations will be made in a proportionate way. According to Childress et al. , proportionality:

‘Is essential to show that the probable public health benefits outweigh the infringed general moral considerations […]. For instance, the policy may breach autonomy or privacy and have undesirable consequences. All positive features and benefits must be balanced against the negative features and effects […]’ [10: 173, our italics].

However, proportionality is also a methodological principle. In a manner different to the principles we have so far discussed, it forms the basis for casuistic reasoning in relation to problems of individual welfare versus collective benefit in public health. Singer et al. [ 11 ], for example, argue that revelations of Chinese ethnicity in the Canadian outbreak of SARS demonstrate the need for fundamentally careful consideration before the release of private information in cases of pandemic disease. Beyond this, the balancing of private goods and public interests provides a way into debating many of the central problems of ethics in public health policy and practice such as resource allocation, the location of individual responsibility and foundational rights in the sphere of health and health care. It is this idea of debating the proportionality of interventions, and the help it offers in advancing understanding of situations, that leads us to our conception of the principle as partly methodological. Even though a methodological principle, it is normative nevertheless, and thus we include it in our concise set of principles: as with the other principles so far discussed, it contains essential prima facie moral guidance for public health practitioners.

Process foundations for teaching and learning in public health ethics: case studies and problem based-learning

Having outlined and discussed the seven principles that form the content basis of teaching on our short course, we turn now to describing and discussing the processes for teaching and learning related to these content foundations. Our approach can be summarised as the use of case studies to stimulate debate and discussion around the principles that we have identified and discussed. The intention of case study-based debate is to allow reflection and awareness that ethical difficulties in public health are not ‘black and white’; we cannot expect easy answers, or possibly any definite answers at all [ 9 , 23 , 24 ].

Why case studies?

Case studies in this context are short narratives describing a real-world or at least realistic example of a professional ethical dilemma. Case studies have a central role in the process of teaching and learning that aims to build the capacity of moral awareness and discrimination. The use of case studies has been widespread and successful in various areas of medical ethical education generally [ 25 ] and bioethics more particularly [ 26 ]. They also have a history of success in public health, in particular public health ethical-scientific discourse [ 27 ].

The narratives embodied in case studies help to identify and illustrate ethical difficulties. Case studies, with their obvious focus on practice and practical examples, can help to unpack difficulty that is simply impossible through purely abstract ethical reasoning or generalised philosophical examples. They also offer the possibility of genuinely inter-disciplinary dialogue between public health practitioners and moral philosophers (both likely to be involved in ethics-related teaching and learning in this field), at least partly because they are ‘acceptable currency’ to both sets of people. The requirement for inter- disciplinary dialogue extends, moreover, beyond simply public health practitioners and moral philosophers to a range of others (for example, politicians and policy makers) simply by virtue of what public health is and what it tries to do.

Case studies are not simply ‘administered’. Their form demands, and their function yields, dynamic group discussions in which the participants’ specific professional and personal experience can be brought to bear on the problem highlighted within the case concerned.

An important benefit of a case study-type approach centrally embedded in public health ethics teaching and learning is that it allows access to an enormous range of sources and experience. There is perhaps a tendency to think of case studies as artefacts solely designed by those charged with the teaching and learning process. Of course, the development and use of case studies designed by those teaching short courses in ethics is important. But student-generated experience as material for case studies is equally, if not more, valuable because it is rooted in the professional lives of learners. Sources such as books (both fiction and non-fiction) and films are also rich veins that can be tapped in the search for source material for ethics-related case studies [ 28 , 29 ].

Case studies as an aid to problem-based learning: the schedule for a short course in public health ethics

Having described the value of case studies for public health ethics teaching and learning in terms of their relevance, applicability and capacity to encourage inter-disciplinary dialogue, we now turn to exemplifying a schedule for a short course in this area. In doing so, we start to draw out the central importance of problem-based teaching and learning in our schema. (Please see Table 1 for a summary of this schedule).

In a first phase, our course begins with an introductory discussion focusing particularly on the concept of public health. What do we mean by this and in particular, what do we mean by its two constituent words, ‘public’ and ‘health’? Understanding these terms has essential relevance to ethics-related discussion of the field. The term ‘public’, for example, could be understood as the subject of action (the public being represented by public institutions) or as the object of action (someone acting to protect or improve the public’s health or pursuing a public good) [ 14 , 30 , 31 ]. Furthermore, different conceptions and criteria of health exist. Equally, students need to be encouraged to develop an awareness that how they understand ‘health’ (both generally and in the context of public health particularly) will have implications for how they frame ethical discourses and move towards resolving moral problems. Yet the task of defining and describing ‘health’ itself is complex and ridden with competing values [ 32 , 33 ]. As a consequence, the concept of public health can also be interpreted differently [ 34 , 35 ]. Encouragement is made towards the idea that our understanding of the term ‘public health’ and its constituents ’public’ and ‘health’ is likely to be neither wholly objective nor completely neutral; our talk is always (at least partly) driven by ideology [ 13 , 20 , 22 ].

Debate about the nature of health and its relation to allied concepts such as well-being, illness, disease and disability is important both to help frame and understand the discussions that follow; and also to prompt at the earliest stage of the course dialogue between its participants. Our experience is that those undertaking the kind of course we describe may enter it believing that they broadly share similar conceptions of ‘health’ and ‘public health’. This may of course be true, but we have found that going back to first principles in the way that we have described is often a means to exposing differences in understanding, which warrant fruitful exploration as part of the ethics-focused debate that follows.

After this introductory session, we move on to begin discussion of ethics, focusing on its capacity to inform decision-making [ 36 ]. Our concern is to present ethics as a systematic field of study and a major historical contributor to the development and shaping of society. We also attempt to explain and clarify the normative character of much ethical thinking, a central feature of its character that is likely to differ from other fields and disciplines with which participants may be more familiar. Although of course we have so far argued that much public health practice is predicated on normative assumptions and beliefs, this is not often rendered visible. Perhaps the greatest difference between the discipline of ethics and other potential disciplinary contributors to the public health curriculum lies in the normative focus of ethics being explicit .

Ethical argument and resulting positions are generally driven by the belief that this is the way that things ought to be in the world [ 37 ]. This is the essential meaning of normativity in ethics. Public health practitioners – our course participants – may struggle with the move from ‘is’ to ‘ought’ that is this central characteristic of normative ethics. They are likely to be much more familiar with fields and disciplines in which evidence is developed and presented: and arguments may be made for a particular position; but normative declarations are not (or at least not often) made in relation to these processes. To take a brief example, a public health practitioner may, in his or her practice or other study, have gathered evidence for the existence of inequalities in health. They will most likely have views on what this evidence implies for the lives of individuals and populations. But it is unlikely (other than perhaps in a personal sense), that they would have been required to develop a normative argument related to inequalities (e.g. health inequalities should be regarded as morally unacceptable when the determinants of these inequalities are avoidable). Ethics easily assumes this latter kind of position, but reaching it may be unfamiliar for our participants.

This example emphasises the importance of our problem-based learning approach within this course. By confronting our participants with a problem and asking what should be done, and, importantly, what we need to explore and understand better to be able to justify such action, they are guided, or hopefully guide themselves, through an essential process. This is the process that requires them to account for, and come to conclusions about, not simply their knowledge and understanding of the issue being considered, but also their experience (or potential experience) of that issue. This connection of knowledge, understanding and experience is likely to yield different positions and conclusions than one founded simply on cognition. It is likely to allow and facilitate the adoption of normative positions (this is what I should do, or what I should believe), which can then be subject to scrutiny. This is because we are ‘allowing’ the expression of values through emphasising the importance of experience (that on which, in large part, our values are founded) [ 38 ].

At the same time, students will need points of reference and justification for the ethical positions that they are constructing through their consideration of problems and cases. Thus, the step of our teaching and learning is to introduce the principles (as described and discussed above) that provide normative guidance (and which of course have been developed through the lengthy application of careful thinking related to the nature and purpose of health care, among other areas of human endeavour). Developing thinking about practical experience (either one’s own, or in a vicarious sense) and striving for justifications or actions – or omissions – forms the essence of ethical deliberation. This is practiced in discussing a case together (see phase 2, Table 1 ).

As we made clear in the introduction to this paper, balancing possible courses of action and coming to conclusions about what should be done is a key feature of professional life in public health. These conclusions are not simply (or even most importantly) practical ones; they are ethical. Our interest in developing the course we are describing and discussing emerged from a belief that frequently there is little or no training or preparation for ethical thinking and understanding in the process of the formation of public health professionals. In our course up to this point, we have demonstrated the need for this understanding, proposed both tools (the principles) and methods (the use of case studies and the application of problem-based learning in the context of the methodology of ethics) and are now at the final stage of applying these.

In this next phase, students are divided into small groups of between four and six, depending on overall group size. Each group receives a different case study, which illustrates an underlying ethical problem or conflict. (Please see Case study: Maria Morales for one example case study used by the authors in their teaching and learning). They also receive a hand out that is their ‘toolbox’ for approaching and dealing with the problem. This contains a summary of the principles that we have elucidated and a checklist/aide memoire for their application. (Please see “Principles checklist/aide memoire”).

Case study: Maria Morales

Maria Morales, head of the “Infectious Disease Control” unit of the Ministry of Health of the State X, is asked by her minister to make a suggestion if measles immunisation should be made mandatory in their region as recently 2 children died after a measles outbreak. State X has an insufficient immunisation rate (1 st dose 70%, 2 nd 55%). Maria finds out that obligatory measles immunisation is effectively implemented in regions in Hungary and the Czech Republic. She knows her minister is taking her advice most seriously. What should she do? [ 39 ].

Principles checklist/aide memoire

Non-Maleficence

✓ Will no one be harmed by the proposed intervention?

✓ Are especially children prevented from harm?

✓ Is the intervention of any good to every single person taking part in this intervention?

✓ Overall, for both non-maleficence and beneficence, is it possible to assess whether more benefit than harm is produced by intervening (or not intervening) and, if so, on what side (benefit or harm) does the equation finally fall?

Health Maximisation

✓ Is the proposed intervention effective and evidence-based? Does it improve population health?

✓ Does it have a sustainable, long-term effect on the public’s health?

✓ Is there a community added value to the proposed intervention?

✓ Is the proposed intervention cost-effective?

✓ Awareness of scarcity of public money; saved money can be used for other goods and services.

Respect for Autonomy

✓ Does the intervention refrain from employing coercion and manipulation? Does it foster free choice?

✓ Is there really ‘informed consent’ to take part in the intervention?

✓ Is self-responsibility not only demanded but also possible for every person?

✓ Are privacy and personal data respected?

✓ If the intervention is paternalistic, is this justifiable?

✓ Does the intervention promote the exercise of autonomy?

✓ Is no one (including third parties) stigmatised, discriminated against or excluded as a consequence of the proposed intervention?

✓ Is the institution proposing the intervention publicly justified and acting transparently?

✓ Is the proposed intervention not putting sub-populations at risks of being excluded from social benefits and/or universal access to health care?

✓ Does the intervention exacerbate social and health inequalities (inequities)? Does it fight inequalities (inequities)?

✓ Does the intervention consider and support vulnerable sub-populations (e.g. migrants)?

✓ Does the intervention promote rather than endanger fair (and real) equality of opportunity and participation in social action?

✓ Does the intervention refrain from eroding a sense of social cohesion and solidarity?

✓ Is the intervention the least infringing of possible alternatives?

✓ Are costs and utility proportional?

Each small group discusses the case that it has been given. They can follow the detailed steps as presented in Table 2 . Participants are asked to:

Identify as specifically as possible what they believe to be the ethical challenges and potential conflicts within the case;

Frame these challenges in explicitly ethical language (i.e. according to the principles and other normative moral theory so far discussed within the course and contained in their ‘toolbox’);

Suggest a ‘solution’ or otherwise a way of dealing with the case through the development of an ethical argument that again uses the resources of the ‘toolbox’.

At this last stage of the small group work phase, the groups formulate a justification for action that both elucidates the normative processes that have led them to their conclusion; and present an argument as to how and why they have rejected and would deal with alternative possible normative positions. (For example, in the presented case study “Maria Morales”, population benefit versus parental autonomy). Each small group in turn presents their justification and anticipation of counter-argument to the group as a whole in a plenary session. The emphasis in this session is not simply on exposition but also on continuing and developing the ‘dialogue of argument and understanding’ that the small group work has begun to generate.

Developing the ethical persona of the public health practitioner

In this paper, we have presented and justified our short course framework for ethics teaching and learning in public health. Our premise was that public health practitioners are frequently faced with difficult situations in which they have to make decisions with explicitly moral dimensions and yet they receive little training in the area of ethics. The crowded nature of the public health curriculum, and the nature of students participating in it, required us to devise and develop a short course, and to use techniques, that were likely to provide both a relatively efficient introduction to the processes, content and methods involved in the field of ethics; and make use of the understanding and experiences of our likely participants.

Our aims in presenting the framework have been modest. Primarily, they are to raise awareness of ethical issues within the practice of public health; and to provide a ‘toolbox’ to support thinking and reasoning (and possibly decision making) on the part of public health professionals in training. The modesty of these aims stems, as we have made clear, from a keen pragmatism about what can actually be achieved in this context.

Of course, this is not to exclude the fundamentally important proposition that this kind of introduction can only ever provide a ‘snapshot’ for participants of an enormous and (we believe) essentially interesting territory. In view of the fact that the endeavour of teaching ethics is currently a work under development in most European schools of public health, the approach described and discussed here can perhaps be used as a ‘minimum standard’ curriculum for teaching and learning in this area. We argue, however, that the limitation of our highly specific approach to a deeply complex area is outweighed by its forming at least the basis for independent thought, which we hope will extend well beyond the time boundaries of the short course itself.

We would hope that our short course model, or something approaching it, could be used until it is possible for programme directors to be able to designate more space for ethics modules in their programmes and until more fitting curricula, broadly encompassing ethics, are made available. Our approach in this short course framework has been to develop the realisation that independent ethical thought is possible, but that circumstances require guidance and direction. In this respect, we suggest that although the course may be considered as being partly akin to what Dawson [ 43 ] has described as ‘outside in’ ethics – the idea that principles act from the outside and guide practitioners in their ethical behaviour – it also sows the seed through case study deliberation for the emergence of ‘inside out’ (also from Dawson) – oriented ethical practitioners.

‘Outside in’- oriented ethics has value, but also has limitations, especially in the regard that, without principles being there, or being readily applicable (which may frequently be the case given the complexity of public health practice), the practitioner is rendered more or less helpless. While our course is based, as we have described, on principles, we have tried to make clear that it is not in any sense about ‘outside in’ rote learning of these principles. Our case study and problem-based learning approach allows the possibility of ‘inside out’ ethics. We encourage through our methods the development of independent ethical thinking on the part of those involved in public health. The essence of an ‘inside out’ approach lies in the development of moral capacity on the part of the individual; encouraging them, along Aristotelian lines, to engage in examination and reflection on their life and experience in order to come to a sense of what it is to live ethically and to inhabit an ‘ethical persona’. Thus moral sense and ethical expertise is developed from within. We believe that given the current organisational and institutional constraints of the public health curriculum, our short course will go some way to both provide future public health practitioners with a tool-box founded on our seven principles framework of public health ethics and also foster the development through its focus on experiential and problem-based learning, and the active application of case studies, of ‘inside out’ ethics.

GaareBernheim R: Public health ethics: the voices of practitioners. J Law Med Ethics. 2003, 3: 104-109.

Google Scholar

Duncan P: Values, Ethics and Health Care. 2010, London: SAGE

Aceijas C, Brall C, Schröder-Bäck P, Otok R, Maeckelberghe E, Strech D, Tulchinsky T: Teaching ethics in schools of public health in the European region – results of a screening survey. Public Health Rev. 2012, 34 (1): 146-155.

Kass N: An ethics framework for public health. Am J Public Health. 2001, 91: 1776-1782. 10.2105/AJPH.91.11.1776.

Article Google Scholar

Eckles RE, Meslin EM, Gaffney M, Helft PR: Medical ethics education: where are we? Where should we be going? A review. Acad Med. 2005, 80 (12): 1143-1152. 10.1097/00001888-200512000-00020.

Cribb A: Health and the Good Society. 2005, Oxford: Oxford University Press

Book Google Scholar

Downie RS, Tannahill A, Tannahill C: Health Promotion: Models and Values. 1997, Oxford: Oxford University Press, 2

Lacey AR: A Dictionary of Philosophy. 1976, London: Routledge and Kegan Paul

Beauchamp TL, Childress JF: Principles of Biomedical Ethics. 2009, New York: Oxford University Press, 6

Childress JF, Faden RR, Gaare RD, Gostin LO, Kahn J, Bonnie RJ, Kass NE, Mastroianni AC, Moreno JD, Nieburg P: Public health ethics: mapping the terrain. J Law Med Ethics. 2002, 30: 170-178. 10.1111/j.1748-720X.2002.tb00384.x.

Singer PA, Benatar SR, Bernstein M, Daar AS, Dickens BM, MacRae SK, Upshur REG, Wright L, Shaul RZ: Ethics and SARS: lessons from Toronto. Br Med J. 2003, 327: 1342-1344. 10.1136/bmj.327.7427.1342.

Powers M, Faden R: Social Justice: The Moral Foundations of Public Health and Health Policy. 2006, New York: Oxford University Press

Daniels N: Just Health: Meeting Health Needs Fairly. 2008, Cambridge: Cambridge University Press

Schröder-Bäck P: Ethische Prinzipien für die Public-Health-Praxis. Grundlagen und Anwendungen[Ethical Principles for Public Health Practice. Foundations and Applications]. 2014, Frankfurt a.M: Campus

Engelhardt HT, Wildes KW: The four principles of health care ethics: why a libertarian interpretation is unavoidable. Principles of Health Care Ethics. Edited by: Gillon R, Lloyd A. 1994, Chichester: Wiley, 135-147.

The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research: The Belmont Report. Ethical Principles and Guidelines for the Protection of Human Subjects of Research. 1978, Washington, D. C: United States Government Printing Office

Jonsen AR: Do no harm: axiom of medical ethics. Philosophical Medical Ethics: Its Nature and Significance. Edited by: Spicker SF, Englehardt HTJr. 1977, Dordrecht, the Netherlands: Springer, 27-41.

Chapter Google Scholar

Smith CM: Origin and uses of primum non nocere - above all, do no harm!. J Clin Pharmacol. 2005, 45: 371-377. 10.1177/0091270004273680.

Beauchamp TL: The ‘four principles’ approach to health care ethics. Principles of Health Care Ethics. Edited by: Ashcroft R, Dawson A, Draper H, McMillan J. 2007, West Sussex, England: Wiley, 3-10. Second

Seedhouse D: Health: The Foundations for Achievement. 2001, Chichester: Wiley, 2

Veatch R: Doctor does not know best: why in the new century physicians must stop trying to benefit patients. J Med Philos. 2000, 25: 701-721. 10.1076/jmep.25.6.701.6126.

Boorse C: Health as theoretical concept. Philos Sci. 1977, 44: 542-573. 10.1086/288768.

Veatch RM: A Theory of Medical Ethics. 1982, New York: Basic Books

Czabanowska K, Menzies LA: English for European Public Health. A Specialised Course for Students and Professionals. 2007, Maastricht: Maastricht University Press

Pence GE: Classic Cases in Medical Ethics. Accounts of Cases that Have Shaped Medical Ethics, with Philosophical, Legal, and Historical Background. 2000, Boston: McGraw Hill, Third

Veatch RM, Haddad AM, English DC: Case Studies in Biomedical Ethics: Decision-Making, Principles, and Cases. 2009, Oxford: Oxford University Press

Coughlin SS, Soskolne CL, Goodman KW: Case Studies in Public Health Ethics. 1997, Washington: American Public Health Association

Halper E: Ethics in film. APA Newsletter. 2003, 3 (1): 191-195.

Macnaughton J: Literature and ‘the good doctor’ in Ian McEwan’s ‘Saturday’. Med Humanit. 2007, 33: 70-74. 10.1136/jmh.2007.000259.

Verweij M, Dawson A: The meaning of ‘public’ in ‘public health’. Ethics, Prevention and Public Health. Edited by: Dawson A, Verweij M. 2007, Oxford: Clarendon Press, 13-29.

Anomaly J: Public health and public goods. Public Health Ethics. 2011, 4: 251-259. 10.1093/phe/phr027.

Boorse C: Concepts of health. Health Care Ethics: An Introduction. Edited by: VanDeVeer D, Regan T. 1987, Philadelphia: Temple University Press, 359-393.

Nordenfelt L: The concepts of health and illness revisited. Med Health Care Philos. 2007, 10: 5-10. 10.1007/s11019-006-9017-3.

Goldberg D: In support of a broad model of public health: disparities, social epidemiology, and public health causation. Public Health Ethics. 2009, 1: 1-14.

Rothstein MA: The limits of public health: a response. Public Health Ethics. 2009, 2 (1): 84-88. 10.1093/phe/phn041.

Jennings B, Kahn J, Mastroianni A, Parker LS: Ethics and Public Health: Model Curriculum. 2003, New York: Association of Schools of Public Health

Loughlin M: Criticizing the data: some concerns about empirical approaches to ethics. J Eval Clin Pract. 2011, 17 (5): 970-975. 10.1111/j.1365-2753.2011.01750.x.

Carr D: Making Sense of Education. 2003, Abingdon: Routledge

Schröder-Bäck P, Brand H, Escamilla I, Davies JK, Hall C, Hickey K, Jelastopulu E, Mechtler R, Volf J: Ethical evaluation of compulsory measles immunisation as a benchmark for good health management in the European Union. Cent Eur J Public Health. 2009, 17: 183-186.

Finder-Stone P: Weaving ethical threads into the nursing curriculum fabric. Teaching Ethics: An interdisciplinary Approach. Edited by: Ashmore RB, Starr WC. 1994, Milwaukee: Marquette University Press, 97-111.

Horster D: Einleitung. [Introduction]. Moralentwicklung von Kindern und Jugendlichen. [In Moral Development in Children and Adolescents]. Edited by: Horster D. 2007, Wiesbaden: VS Verlag für Wissenschaften, 7-16.

Marckmann G, Strech D: Konzeptionelle Grundlagen einer Public Health Ethik. [Conceptional basics of a public health ethic]. Public Health Ethik. [In Public Health Ethics]. Edited by: Strech D, Marckmann G. 2010, Münster: Lit, 43-65.

Dawson A: Professional codes of practice and ethical conduct. J Appl Philos. 1994, 11 (2): 145-153. 10.1111/j.1468-5930.1994.tb00104.x.

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Acknowledgements

The authors want to acknowledge the employing institutions of the authors: Maastricht University, King’s College London and the École des hautes études en santé publique. In particular we want to thank the INPES Chair in Health Promotion at the École des hautes études en santé publique that supported the initial discussions of this paper among PSB, PD and WS. The authors would also like to thank two reviewers for their very helpful comments.

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Department of Human and Social Sciences and Health Behaviour, Ecole des Hautes Études en Santé Publique, Avenue du Professeur Léon-Bernard, CS, 74312, 35043, Rennes, France

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PSB, PD and WS have drafted the article. CB and KC contributed to the development of the final draft. All authors read and approved the final manuscript.

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Schröder-Bäck, P., Duncan, P., Sherlaw, W. et al. Teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes. BMC Med Ethics 15 , 73 (2014). https://doi.org/10.1186/1472-6939-15-73

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As part of CDC’s ongoing efforts to support state and local health departments, the Public Health Ethics Unit has developed a training manual to be used as a tool to strengthen public health ethics capacity at the local level. The manual includes an introduction to public health ethics, relevant case studies, suggestions for integrating ethics into health departments, and additional resources. The Student version of the manual may be downloaded here; the Facilitator version is available upon request.

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The Centers for Disease Control and Prevention (CDC) and the National Association of County and City Health Officials (NACCHO) announce the availability of a Web-on-Demand e-Learning module, Good Decision Making in Real Time: Practical Public Health Ethics for Local Health Officials. The Centers for Disease Control and Prevention (CDC) and the National Association of County and City Health Officials (NACCHO) announce the availability of a Web-on-Demand e-Learning module, Good Decision Making in Real Time: Practical Public Health Ethics for Local Health Officials.

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Peer-reviewed

Research Article

Climate change and women’s mental health in two vulnerable communities of Bangladesh: An ethnographic study

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Ceped, Université Paris Cité, Inserm, IRD, Paris, France

Roles Investigation, Writing – review & editing

Affiliations BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh, International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh

Roles Investigation

Affiliation BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh

Roles Conceptualization, Validation, Writing – review & editing

Affiliation National Institute of Mental Health and Hospital, Dhaka, Bangladesh

Roles Conceptualization, Formal analysis, Funding acquisition, Methodology, Supervision, Validation, Writing – review & editing

Affiliations Ceped, Université Paris Cité, Inserm, IRD, Paris, France, Institut de Santé et Développement, Université Cheikh Anta Diop, Dakar, Sénégal

Jean-Marc Goudet,
Faria Binte Arif,
Hasan Owais,
Helal Uddin Ahmed,
Valéry Ridde

Published: June 27, 2024
https://doi.org/10.1371/journal.pgph.0002080
Reader Comments

Climate change is one of the most significant challenges humanity faces in the 21st century, with its health impacts being profoundly felt in the most vulnerable countries. However, the mental health impacts of climate change, particularly concerning social inequality and gender dynamics, are less documented in the Global South. This paper focuses on the impact of climate change on women’s mental health in two vulnerable communities in Bangladesh. This study employed qualitative methods, including, in-depth interviews, and focus group discussions (FGDs). The communities were selected based on their vulnerability to climate change. A total of 80 participants were selected using snowball sampling, and 55 interviews and 6 FGDs were conducted. Women are particularly vulnerable to climate change impacts on mental health due to their gender roles and responsibilities. Responsible for taking care of their families, they have to face additional challenges due to climate change impacts, such as increased workload, food insecurity, and social insecurity when their husband migrates to the cities for jobs. Women also face social and cultural barriers, which exacerbate their vulnerability to climate change impacts on mental health. Socioeconomic and environmental determinants appear to be embedded and lead to psychological suffering in relation to social roles and gender norms. Interventions should be designed to address the specific needs and challenges faced by women in these communities. Policymakers should take a gender-sensitive approach to address the mental health impacts of climate change in these communities. This study contributes to the growing body of research on the gendered impacts of climate change with a trajectory approach and provides insights for future research in this area.

Citation: Goudet J-M, Binte Arif F, Owais H, Uddin Ahmed H, Ridde V (2024) Climate change and women’s mental health in two vulnerable communities of Bangladesh: An ethnographic study. PLOS Glob Public Health 4(6): e0002080. https://doi.org/10.1371/journal.pgph.0002080

Editor: Valentina Gallo, University of Groningen, NETHERLANDS

Received: May 27, 2023; Accepted: May 27, 2024; Published: June 27, 2024

Copyright: © 2024 Goudet et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Due to the particularly sensitive data privacy issues in mental health, the data is only accessible after an express request to the IRB of of BRAC James P Grant School of Public Health. The contact email is [email protected] .

Funding: We wish to thank the French National Research Agency (ANR) for co-funding this research as part of the call “Make Our Planet Great Again” (MOGPA) (JMG, FBA, HO, VR) and the National Center for Resources and Resilience (Cn2r) for the postdoctoral fellowship (JMG). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The ongoing climate crisis represents the greatest threat of this century to both human existence and biodiversity [ 1 ]. Climate change (CC) refers to a long-term shift in the weather patterns that can be identified due to natural processes and anthropogenic factors [ 2 ]. Since 2010, CC impacts on mental health are described as a global emergency. Different frameworks have the strength of showcasing various determinants in a cross-cutting approach supported by epidemiological evidence. However, very few highlight the socio-economic and environmental factors in their interactions and how they contribute to mental health trajectories at the individual level. Berry et al., described two main causal pathways between mental health outcomes and climate impacts [ 3 ]. Direct consequences occur after acute events and are described in terms of depression or psychological trauma [ 4 ]. Indirect consequences could be caused by the changes in ecosystems through different determinants such as economy, migration, or social structures [ 4 ]. For example, long-term changes such as chronic drought increased the distress of the rural population [ 5 ]. Additionally, the cumulative effects of multiple stressors associated with climate change can intensify existing mental health issues or lead to the emergence of new ones. Such stressors may include food and water insecurity [ 6 – 8 ], loss of livelihoods [ 9 ], displacement [ 10 ], and social networks [ 11 ]. Yet, a knowledge gap remains to characterize the chronic effects of slow-onset events on mental health issues [ 12 ]. Siegele defines slow-onset events as phenomena with chronic changes (increasing temperature, sea-level rise, salinization, ocean acidification, loss of biodiversity, etc.) as opposed to acute events (storms, floods, acute drought, etc.) that are not permanent and occur in a short time frame [ 13 ]. As the slow-onsets and their chronic consequences will keep rising, it is important to better understand the underlying mechanisms to provide adequate actions. Moreover, the slow onset events are disproportionally affecting the population living in the Global South as they are more dependent on natural resources such as water and crops. While women are considered at higher risk of suffering from post-traumatic stress disorder after any natural disaster [ 14 ], how climate changes affect their mental health remains underexplored in the Global South. Recent results show how climate change, and specifically extreme weather events do affect the social structure. Women’s vulnerabilities are shaped by cultural and gender norms, as well as their lower socio-economic status in society, which manifests itself in their domestic role, decision-making within the household, and it is accentuated during climatic events [ 15 ] and in the context of a changing climate [ 16 ]. Indeed, these events prompt men to leave their communities in search of income, while women are trapped behind to shoulder caregiving responsibilities and additional duties [ 17 ]. But the underlying mechanisms of action are not well-explained. Moreover, there is limited data available from countries in the Global South, which are often the most vulnerable to the impacts of climate change.

Bangladesh is one of the countries most exposed to climate events (cyclones, tidal surges, floods, periods of drought) [ 18 ], and over the past decade, acute events have become increasingly frequent and intense due to climate change [ 19 ]. Simultaneously, the nation faces slow-onset events (acidification, increasing temperature, salinization, loss of biodiversity, etc.) that have led to environmental disruptions [ 20 , 21 ]. More than 60% of the population lives in rural areas and is significantly affected by slow-onset events [ 22 ]. The country is now confronting a dual crisis with the emergence of a mental health crisis. Recent studies highlight the substantial mental health burden in Bangladesh, with a 2019 average prevalence of mental disorders in the population reaching 16.8% [ 23 ]. A 2020 study published showed that 20% of rural women were screened for a major depression disorder [ 24 ]. However, mental health service providing infrastructure is limited, and very few psychiatrists are available in the country, with an estimated 260 psychiatrists for the 162 million people living in the area [ 25 ]. Moreover, research in the mental health field is underfunded and women’s mental health has been identified as one of the scientific priorities in recent times [ 26 ].

The objective of this study is to explore how climate change affects the mental health of women in vulnerable communities in the Global South especially in Bangladesh.

Material and methods

Study setting.

This study is nested within the Clim-HB project, a large public health research that focuses on health system resilience and climate change [ 27 ]. Our research took place in two vulnerable communities in Bangladesh, one in a rural area which is disaster prone and the other in an urban area chosen due to their vulnerability and exposure to climate change.

In the rural community, the local population relies on agriculture and aquaculture (fish and shrimp culture) for their livelihoods. This community, located in the southwest region of the country, is subject to both slow-onset and acute climatic events. Moreover, 20% of the population experiences a seasonal migration after the monsoon due to the lack of employment. The second setting is a slum in the capital city. The investigation primarily focused on the poorest households in the slum, who live in stilt houses built over a canal. This setting is particularly exposed to pollution and extreme heat. These field sites are part of a larger public health research project within the framework of the Clim HB project [ 27 ]. Both populations share a pattern of migration, as a large portion of the families encountered in the slum originated from coastal regions of Bangladesh and migrated for economic reasons and sometimes environmental ones. Coastal regions are subject to significant environmental transformations as well as a scarcity of jobs, which is also related to the urbanization of the country [ 20 – 22 ].

Conduct of study

We conducted a qualitative research including in-depth interviews, and focus group discussions [ 28 ]. The participants were selected using snowball sampling. For our snowball sampling, we initiated the procedure by pinpointing and interviewing a handful of participants from the chosen communities after briefing community leaders about our research objectives. In the rural area, our starting point was individuals who discussed the effects on shrimp production due to climate changes and those who proactively invited us for discussions. These primary participants then directed us to other potential participants, typically other family members or neighbors. In the urban slum, initial participants were selected based on the vulnerability of their housing and its location which was prone to flooding. These initial participants then recommended other potential participants, often including their family members or neighbors. It is essential to highlight that this sampling method proved invaluable In the communities we have studied. Using the trust and existing relationships of our initial participants, we were able to tap into a wider network, providing us with diverse and comprehensive perspectives. This approach also ensured that we operated within a “milieu of mutual acquaintances”[ 28 ], thereby establishing social relationships with participants, which enhanced the depth and credibility of our findings. Participant observation allowed us to understand the lived experiences of these communities and to familiarize ourselves with the population. The primary tool for this technique was an observation guide. We took detailed notes, capturing observed behaviors, interactions, and environmental factors in our field journal. In-depth interviews were essential in exploring the social trajectories and mental health states of individuals. We employed a semi-structured interview guide, ensuring consistency across interviews while permitting respondents to convey their unique experiences. Focus group discussion (FGD) shed light on communal perceptions, collective experiences, and community-level challenges related to the impacts of climate change. For these discussions, we used a thematic guide.

Each interview and FGD were recorded. A sociologist and public health physician, led the data collection with two research assistants (FRAs), both trained in qualitative research methods. Both RAs were fluent in Bangla and English and had prior experience working in similar community settings. A public health researcher and a psychiatrist supervised and validated the various data collection guides used in the study. Adhering to the reflexive ethnography approach [ 29 ], we conducted our study within settings characterized by mutual acquaintance in each site and over an extended period. We embarked on three extended stays in the communities over a year and a half, enabling the collection of ethnographic materials from our field journals and conducted interviews or FGDs. Data saturation was achieved during the third phase of data collection, as we could explain the observed effects and discuss them with participants. In practical terms, after each in-depth interview and FGD, we held a collective debriefing. Also, at the end of each day, we dedicated several hours to elaborating on our field notes. A debriefing session was held the following morning. This consistent routine not only reinforced reflexivity but also allowed for the ongoing adaptation of our methods, ensuring the robustness and integrity of our data collection process.

To reflect the seasonal variations that could influence mental health issues, data were collected during two period covering three months in total: in March and April during the hot season and in October 2022 after the monsoon. In each site, approximately fifteen households were followed throughout both data collection periods. We conducted interviews with various household members to triangulate the data, which helped improve the reliability and quality of the information gathered. The results of our analyses were then triangulated with those from the literature to bolster the objectivity of our findings. This approach allows us to thoroughly comprehend the barriers and coping strategies at the household level and facilitates data triangulation within the family unit, ensuring a robust and quality data collection. This method allowing us to reconstruct social trajectories and assess the impact of specific environmental events on women’s mental health. Table 1 shows that the study comprised a total of 55 interviews and 6 FGD (n = 80). Only relevant data for the research question were retained for the analysis.

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https://doi.org/10.1371/journal.pgph.0002080.t001

All the interviews were conducted in Bengali with the presence of a Bengali-English translator, except for one interview which was directly conducted in English with a health professional. During the second fieldwork, the researchers returned to the same individuals to conduct a follow-up and refine the data obtained from the first fieldwork. In each site, around fifteen families were interviewed. When possible, researchers conducted interviews with different household members, to triangulate and gain a comprehensive understanding of the family’s situation. The audio recordings were transcribed by a native speaker. Observational data were compiled by a sociologist and public health physician after discussion with FRAs to ensure accurate social and cultural comprehension. First, we triangulated data for each respondent to validate key information. Next, we applied a data reduction strategy, focusing on material specifically relevant to our research question. Responses from each participant were first sorted according to the posed questions. They were then further categorized by gender, age, specific setting, and based on whether participants had current or historical experiences with mental health issues. A thematic analysis was then performed based on the social determinants framework from WHO and Lund et al. [ 30 , 31 ]. This process enabled the identification of specific themes and subthemes pertinent to our research problem. Those selected for detailed analysis were recurring patterns observed across various sources, which highlighted the intricate interplay between women’s mental health and climate change. The results section delineates the themes and subthemes identified through this thematic analysis.

Data analysis

To understand how power relations among gender are constituted in a changing climate, it was combined to specific dimension (access to resources / division of labour within and beyond the household) from the gender framework [ 32 ]. Following this, emerging themes were identified and integrated into the framework analysis. This dual methodology enabled us to systematically pinpoint emerging themes and sub-themes, while also allowing for the revisitation and revision of our codes as our analysis unfolded.

The authors had access to non-anonymized individual participant data, but it is important to note that the data presented in this study have undergone a rigorous anonymization process and have been maintained with strict confidentiality.

Ethics declarations

All participants provided signed consent to participate. Written consent was obtained from both the parents and the individuals themselves for participants under the age of 18, ensuring that both parties were informed and gave their consent to take part of this study. The study protocol was reviewed and approved by the ethics committee from the Institutional Review Board (IRB) of the BRAC James P Grant School of Public Health, BRAC University (ref: IRB‑19 November’20–050), nationally recognized, in Bangladesh.

Using our ethnographic approach and analyzing women’s mental health trajectories, we identified two principal pathways by which climate change influences mental health outcomes along gender lines in these vulnerable communities. These two pathways are found regardless of whether the setting is rural or urban and appear to be interconnected, depending on the social and environmental context; they often manifest as cumulative effects that shape women’s mental health trajectories. The Fig 1 presents the two main pathways through which climate change can affect the mental health of mothers and children. The diagram is based on Berry et al.’s framework, which illustrates how climate impacts on mental health occur in two ways: directly in the case of extreme events and indirectly through livelihood impacts, notably. We aim to demonstrate how this manifests through individual trajectories, highlighting the pathways taken to illustrate the importance of the interaction between socio-economic and environmental determinants. It is not exhaustive, as it does not list all environmental issues and stressors or mental health outcomes, but it provides a foundational explanation that elucidates the differences found in our data analysis. It highlights social resources and strategies and should be understood dynamically, with an interaction between the two pathways at the individual level (see Fig 2 ).

https://doi.org/10.1371/journal.pgph.0002080.g001

https://doi.org/10.1371/journal.pgph.0002080.g002

In presenting the results of our analysis, we will first discuss the "socioeconomic stressor" pathway followed by the "triggering factor" pathway. We will analyze each pathway through subsections that cover stressors, resources, and community vulnerabilities to understand how this shape individual mental health. The roles of gender, social status, and economic opportunities then become crucial.

Socio-economic stressor as an intermediate factor

This first pathway contributes to exacerbating pre-existing gender inequalities arising from economic determinants. It leads to anxiety and depressive-like disorders by amplifying individual vulnerabilities through the impact on livelihood.

The burden of motherhood: Navigating responsibilities and the debt cycle.

Climate change directly impacts the livelihoods of the most vulnerable populations. Due to drought, people from rural setting are experiencing a decline in agricultural production and shrimp yield. The immediate effect on market prices leads to food insecurity that challenges mothers’ responsibilities. It results in increased anxiety for them and potential adverse effects on the physical health of their children. This affects all families in the studied village, including those with a higher socio-economic status.

Mother 1: There are some problems . Suppose , It has become like this due to the price hike . Interviewer (I): Any problems to feed for the children? Mother 1 : In that situation , even if we are starving , we have to feed them . We have to meet their need .

To meet the daily needs of the family members, they seek small loans. This suffering is amplified in households that are already in economic difficulty with debt.

I: You explained this year it did not rain much and it rained heavily for only 2 or 3 days. Do you think you have faced any problems with the lack of rainfall? Mother 2 : We have faced some problems with the lack of rainfall such as we had to irrigate our land manually , and we have faced problems regarding jute retting (…) also with the money lender . So , we had to take money from our relatives as well . It was very stressful .

Those that are in-debt experience the situation as one of the most difficult in their lives.

The situation seems worse for them due to a reduced ability to implement coping strategies. Indeed, the mother 1, whose husband belongs to a higher social class and has attempted to engage in local politics, holds significant social and symbolic capital in the village. The family has better economic resources and greater diversification. They own a pond with fish, a small vegetable garden, and a chicken coop. In the opposite, mother 2 and her husband have a small land and a little grocery store that experienced the COVID crisis, and they both come from impoverished families. Furthermore, mother 2 has two young children, one of whom she is breastfeeding. When asked about her sleep quality, she expresses difficulties regarding feeding issues, the child’s crying, and nutritional problems to her child which directly impact the sleep cycle of the mother.

Mother 2: The child annoys me a lot . I can’t breastfeed her properly (…) I could not sleep previously because of the financial crisis and now I cannot sleep properly because my child cries at night . I: Do you wake up a lot during the night? Mother 2 : He wakes up 2 or 3 times at night . (…) He does not like to eat rice . He always asks for good food like fish , and eggs .

Thus, the effects of climate change tend to follow the socio-economic gradient and the preexistent social inequities. For mother 2, who belongs to a lower class and is heavily in debt, food insecurity leads to disruptions in breastfeeding and undermines her mental health as a caregiver. On the other hand, for mother 1, the psychological distress is less severe due to her financial capacity to cope with the situation. Due to hampering in the breastfeeding leads the nutrients lacking in her child also. The impacts are continuing in the cyclic pattern.

In each instance, these situations were described by the women who bear the responsibility of caring for and feeding the children, while the interviewed men explained their strategies for obtaining income without ever mentioning the mothers’ and children’s circumstances. This indicates the overlooking tendencies of the women’s burden also be discussable.

Similarly, their economic dependence on their husbands sometimes prevents them from leaving their marriage when they consider them unfit to fulfill their roles. This dynamic is a complex interplay of maternal love, the sense of duty as a mother, and economic necessity, which together reinforce their role as the principal providers for their children’s upbringing.

Mother 3: But after marriage , my husband once left his job and started pulling a rickshaw . He used to pull the rickshaw one day and sit at home for three days without earning any money . At that time , I got a feeling of leaving this family and staying separate from my husband . But I couldn’t do that because of my children . I was worried for them .

Income-generating activities in rural areas are not very popular. Due to their limited social capital and reduced agency, women often cannot leave their husbands to seek economic security for their children unless they can receive support from other family members, such as their own parents.

Coping strategies in the household rely on the daughters’ & mothers’ sacrifices.

Coping strategies for the economic situations are dependent on social roles within families and based on a division of labor. Both are exacerbated in a changing climate. Mothers, who are often housewives to raise and educate the children, bear the responsibility of caregiving and thus have fewer options for economic survival strategies. This specifically impacts their mental health.

One of the economic survival strategies presented by a mother from the slum involved not bringing all her children with her. She took the youngest child who was breastfeeding and needed her, while she left her eldest daughter with her mother-in-law. She tries to visit her daughter every three months but describes this situation as very painful for her.

I: How is your sleep now? Are you tensed about something? Mother 4: I am bound to be tensed about my son or my daughter. I can’t do any work. I: If you could tell us what are your thought about your children? Mother 4: The mother has to suffer the pain of the son. Will anyone else suffer? I: Can you sleep properly or you wake up from the sleep early? Mother 4 : I do wake up suddenly . I think what I did to deserve this .

She didn’t want to move to the slum but had to as her husband has job there. They are both from the coastal area where it became hard to survive. Economic migration was thought as a survival strategy decided by the husband.

Furthermore, this economic migration desired by her husband isolates her. Being far from her mother and sister, makes it even more difficult for her to cope with the situation. Besides, her inability to work as she has to take care of her son reinforce her feeling of isolation.

Mother 4: I have to think about the rent , food and everything . But in village , I can share everything with my mother and my sister , which is very much better than this .

Coping strategies such as daughter’s marriage or economic migration are influenced by gender and social roles, and disproportionately affect girls and women. Additionally, she explained that she had to accept being married to financially relieve her parents and could not pursue her studies.

Mother 4: I have five siblings and I am the eldest among the sisters . I studied till class 6 and then my parents married me off to reduce the burden (…) .

Economic strategies for these poor rural families are mainly decided by men so they can provide for their families, even though this becomes increasingly complicated during times of economic and environmental crisis.

In some cases, environmental events shape the economic strategies of the families.

Another participant explained, that after an environmental event, her father decided to marry her.

Mother 5: When I was a child , I observed a lot of cyclones and storms in that area . I: Did your house suffer damage during those cyclones? Mother 5: We had 2 houses, one of them destroyed due to cyclone It happened before the river erosion. And we lost everything including houses in the river erosion. I: When did this river erosion happen? Mother 5: It happened around the mid-2000’s. Before my marriage. I: Did you got married for this reason or there were other problems in your family? Mother 5: Before the river erosion, my family had enough land and we were financially solvent but after the incident poverty hit us. And as we were so many siblings, my father took the decision about my marriage at that time. I: What type of land were those? Mother 5: They were agricultural land. We used to grow rice and other crops on them. I: Can you tell me the size of those lands? Mother 5 : It was a good amount of land . But the whole area was collapsed in the river erosion .

In this case, the environmental event leads to a descendant social mobility of the family. Now living in the slum, this mother face economic constrained that generate anxiety. She is concerned about her children education and a broader vision of their future.

Mother 5: It will be much more reliable for us to survive if my husband gets a new job . We pay 37 USD as rent for one room and , my husband and my children live with me in that one room . I: Can you tell me about your food expenses? Mother 5 : Every month it costs about 90 to 110 USD for food and children’s education . The house rent is separate . (…) I’m having some stress about thinking of the future of my children . Since my husband has no job , I’m concerned about how we will manage the finances of the upcoming days . I’m having headaches because of this stress .

Gender-based violence.

Although such circumstances have been reported even in the absence of a climate crisis [ 33 ], it has been observed that gender-based violence tends to become more severe and frequent, affecting household livelihoods and reducing the opportunities for men to generate sufficient income to meet the family’s needs, sometimes exacerbated by the climate crisis. Indeed, studies highlight an increase in gender violence or intimate partner violence in the context of climate crises and extreme events such as heatwaves, floods or droughts [ 34 – 36 ].

For example, the previous woman who was married after a river erosion and came in the slum faced domestic violence from her unemployed and drug-addicted husband. The reason behind this violence financial hurdles in their livelihood.

Mother 5: Now , I feel stressed , but the reason is different . My husband has no work and he is addicted , because of that we have conflicts in the house and also many other domestic problems , that’s why I have stress and tension all the time . (…) As he used to spend the money on drugs and I tried to convince him , for that reason he used to beat me . (mother 5)

Like other participants, she is particularly isolated, which increases her stress. Her mother-in-law is her close neighbor, support her son, and would report to him any of her complaints. This exacerbates the situation and further contributes to the respondent’s stress and feelings of isolation.

Mother 5: I’m trying to convince my mother-in-law as well , but every time they say that he will quit his addiction soon but it’s not happening and these types of conversations are making conflicts between my husband and his mother and also me . because I’m informing my mother-in-law about my husband’s addiction and somehow , he is also getting to know that I informed his mother . That’s why there are conflicts between us also .

Several women explained to us that when they discuss household budget management with their husbands, particularly in situations of debt, the husbands reprimand them and may physically abuse them.

Mother 6: I used to have arguments with him , regarding the bazaar he used to take money from people , and if I ask questions about it then he was beating me I: He is an alcoholic? Mother 6: No. He used to gossip spend time with his friends and spend money, this is his habit, but our house condition is not good. That’s the reason I: When you used to say something that time he used to beat? Mother 6: I said that, we have children, and they can’t live without eating, he didn’t do the bazaar properly. I: He used to take loans? Mother 6 : Yes . He used to take loans from people but he didn’t go to work , if I ask anything then he used to beat me .

In the rural area, a family facing over-indebtedness also experienced the negative effects of climate change on their mental health. The woman explained that their financial situation was already poor before, but it worsened this year due to a lack of rain. The combination of financial stress and the impacts of climate change can create a challenging situation for families, particularly for women, mothers, and widows who bear the responsibility of caregiving.

Mother 7: We also had problems with the money lender . So , we had to take money from our relatives as well . It was very stressful . I: Do you sleep well at night? Mother 7 : No , I could not sleep previously because of the financial crisis and now I cannot sleep properly because my child cries at night . (…) I: How is your relationship with your husband? Mother 7: The relationship is good but we get into fights for financial matters. People come over to ask for money and get into fights over it. I: Does he physically abuse you along with verbal abuse? Mother 7: He hits me at times. I: When was the last time he hit you? Mother 7 : It starts with an argument . I try to stay patient . People tend to pass judgment as I live in my father’s house . People will talk , that is why I need to remain patient .

This inescapable situation, which is often the result of norms and social pressures placed on women regarding the importance of marriage, can significantly impact their mental health and well-being. Women may feel trapped in their circumstances, unable to leave their marriages or seek help due to the expectations and obligations associated with their roles as wives, mothers, and caregivers.

Mother 7: Because my elder brother is very angry , if he listened to that , my husband is shouting at me or if he is misbehaving with me , then he will beat him . That’s why I don’t . I: He doesn’t know that he used to beat you? Mother 7: Yes, he knows, he tried to get him arrested several times. I: Okay. Mother 7 : But he couldn’t do it because of me . I said how many times people get married , once so let it be , let me stay with one person .

Impacts of social norms on coping strategy.

The isolation experienced by many mothers and young girls in reinforced by the social norms that disregard discussions about psychological issue. This is mechanism that is both self-controlled and encouraged by men due to the significance of reputation within these communities. Reputation is not only important for marrying off their children but also for matters of social dignity.

Mother 8: I always think if I’m able to do this then , it will be better but I don’t have money , so how I’ll do it? My children wanted to live in a good place and to have good food , but I am unable to do anything . No one will help me , I didn’t share with anyone , my son asked me not to share because people will judge us , I am sharing with you guys as you’re listening otherwise , I don’t share with anyone , my son is different , he doesn’t share his sadness with anyone . He has grown up . So , he doesn’t like this .

Climate events as a triggering factor

The second pathway highlighted by our data concerns the triggering effect of climate events, that affects more specifically children, young girls and mothers.

Mothers’ mental health during the COVID-19.

We had already encountered this issue with environmental event during our fieldwork in April 2022 following the COVID-19 pandemic. Some women had mentioned having suicidal thoughts during that period due to their perceived failure in fulfilling their caregiving responsibilities for their children.

Mother 9: During the covid situation , I and my two children were staying with my husband . Whenever our children asked for food , we were not able to provide them with food . That time I had a feeling of committing suicide . I: Have you ever tried to commit suicide? Mother 9 : Yes , I tried to commit suicide once in the middle of the Corona situation . But with the poison bottle in my hand , I couldn’t commit suicide anymore when I thought about my children because I was worried about who’ll look after my children after I will be gone .

Extreme heat and children’s behavior.

During our first field in the hot season, indoor temperatures were very high and significantly higher than outdoor temperatures. Several women reported children’s sleep problems resulting into behavioral issues during the day.

Mother 10: He [ her son ] doesn’t want to go to school; after coming back from school , he lies down and complains that he feels annoyed . (…) We take a shower 2–3 times a day . Sits in the field for the wind . We get very unweary , so we keep splashing water on our bodies . I: How do they [ children ] cope with this? Mother 10: They play with the muddy water and spend their day mainly in the pond. I: Do they get annoyed or not get any sleep because of the hot weather? Mother 10 : They hardly sleep .

After our recorded discussion, she explained that she could not control her child’s behavior, which led her into a negative spiral of increasing anxiety and stress, due to sleep deprivation, compounded by her child’s difficult-to-regulate behavior.

Environmental and specific setting.

The specificities of climate events are important to consider for the policy maker and to help the most vulnerable people. Usually, the main characteristics retained are the duration, frequency, intensity of an event, geographical location such as coastal areas [ 37 ].

During our study, the cyclone Sitrang occurred and was considered by local authorities as having caused much damage due to its low intensity. However, the topography of the part of the slum involved in our study, whose houses are located on a canal, were highly affected.

For the respondent, this cyclone that occurred in October 2022 was much more difficult than one of the last cyclones recognized as having caused the most damage in Bangladesh (Amphan in 2020), even if she was at this time living in the coastal area. Indeed, here she did not receive any assistance or rescue and was trapped in her room, although she took refuges during Amphan.

Mother 11: I think this cyclone was more dangerous . I stayed here the whole night . Yes , it was more dangerous for me (…) there we suffered from damage , one of our big trees was fallen into our house , our house was broken because of that , later we were unable to fix it , the government helped us , and send some dry food .

The inability to access shelters for these impoverished families has made them more vulnerable, even though they have migrated from coastal areas that have been hit by multiple cyclones, but where a refuge had been accessible.

Housing vulnerability in the face of climate events.

This importance of housing was highlighted during the Cyclone Sitrang which occurred in October 2022 and caused significant damage to families living in the slum.

Some of our respondents described the alarming situation for living in the tin houses located on the part of the slum built on stilts above a canal. During the cyclone, the rainwater arrived both from clouds and canal, whose water level began to rise suddenly in the evening.

While the majority of family took refuge in a public building, this one found trapped in her room.

Mother 12: During the cyclone , our house got flooded . The water level was very high because our house was one of the low-level houses in this area . We lost many small household things such as dishes and other belongings during that flood . The water level rose and flooded our house at 11 pm night . The rain started early in the morning . We were sleeping in the house when the water got into our house . We didn’t expect that the water level would rise that much because previously when it rained very little amount of water used got into our house but that night the water level was very high .

The situation was catastrophic as the family faced the prospect of death. While the mother recounts the extreme tension, her children were traumatized, and her daughter remains in shock several days after the event.

Mother 12: When we were standing in bed , I was very tense . We were afraid that if the rain continued , the water will increase , and we will be stuck here and die . One person came during that time and he was asking if someone was stuck here in these houses . We shouted yes and said that we were there . But I don’t know whether he listened to us or not because he didn’t respond . Also , there were so many mosquitoes biting us continuously , so we also asked that guy if he could bring us a mosquito coil . But he didn’t respond . And no one came to rescue us later on . I: How were the babies doing during that time? Mother 12 : We removed the sewing machine from the table and placed the table on the bed . Then we kept our children on top of that table . They sat there the whole night . My daughter cried the whole night because she was very afraid of seeing the water . She is still sick . My son also got sick and was afraid , so I took him to maulana [the religious leader of the community], and now he’s feeling good . But my daughter is still afraid and sick .

Housing is one of the most important factors in resilience or vulnerability to climate events (heat waves, floods or cyclones). In both rural and urban sites, the houses that were less exposed to flooding and more resilient to extreme weather conditions offered greater security and protected mental health outcomes. Here too, gender plays a significant role in the inheritance that is passed down to children, reflecting an inequality in the distribution of material resources. The previous respondent, who is abused by her husband, lives in a tin house, while her brother, who wants to help her, resides in their parents’ hard-building house. She is thus doubly vulnerable as she does not live in durable housing and she does not move because her husband is not a decent enough person for him to live with his family.

I: Why don’t you stay there? Mother 12 : I don’t stay there as my husband is not good . Maybe he can say a bad word , they can hear that . It’s not good to stay with the relative

From family upheaval to climatic events: The trials of a single mother.

One of the most pronounced vulnerabilities to climate events is being a single mother raising her children. One of our respondents describes the alarming situation she experienced when she was caught off guard by the rising waters. Her tin-roofed room is located on a part of the slum built on stilts above a canal. The rainwater arrived both from the clouds and from the canal, whose water level began to rise suddenly in the evening.

Mother 13: Everyone went there in the shelter , in our area , there was so much water , only me , my sister and my child were here , my sister told me that: “no one is here , do you want to die?” . Then somehow , I catch her and I started swimming , it was not the condition of walking . I started swimming , carrying my child on my shoulder , then my sister even got fallen due to the water pressure . So , I came back to this room .

She didn’t go in a shelter as others because she perceived it a risk as a single mother. Her brother also stayed in a tin house during the event.

Mother 13: We were only sitting on the bed , but we were unable to sleep . I: Only you and your son? Mother 13: Yes. Many people went from here, but I didn’t go as I don’t have any place to go, where I’ll go. I: During the night water level was increased, you did not do anything? Mother 13 : Where I will go along with a child , so I didn’t go outside , I stayed here . I didn’t feel good to go any other place with my children , and it was hard for me to go anywhere to take the shelter as a single mother , so that is why I didn’t take the risk , I stay here on the bed only .

She was also afraid by the current situation of water in the road and her inability to protect her son from the water.

I: As everyone leaves here, no one asks you to go with them? Mother 13: Yes, everyone was telling me to go from here, I said no, I’ll not go, I had the courage, and I said that, if my death is written here then I’ll die here along with my son, I’ll not go anywhere. I: Why you did not go anywhere? Mother 13 : I didn’t go , because I didn’t feel good , I had the courage in my mind that nothing will happen , if my death is written here then I’ll die here , if I go there , I can also die there . I had the courage in my mind .

Finally, she left her son with her uncle who stayed as the responsible person of the tong houses. Because her son was crying too much in her arms, as she was too stressed by the situation. Consequently, she stayed alone in the room, feeling very anxious, as she constantly thought about her son and found solers in her prayers.

Mother 13: I am a million times thankful to Almighty Allah . Later on , the next day , the water level decreased and the rain almost stopped . So , as it was not raining , I was less tense . (…) I was so afraid when the water level was increasing , and I thought maybe it was going to be the end , but I performed special prayers , and I prayed to Almighty Allah , to save us and also , and I was also remembering my Almighty Allah’s name again and again , and then I saw in the morning the water level was decreasing . Around 3–4 AM it started to decrease , at that time I was like the water level would not increase , and at that time I was having less stress .

Her initial decision to stay alone in the tin house with her son, awaiting death, is linked to her pre-existing mental condition. This woman has experienced several depressive episodes, including one a few months before the cyclone, which left her bedridden for a month, preventing her from working and taking care of her son, who stayed with his uncle. Her psychological difficulties began during childhood, without her recalling the reason, and then following her marriage and upon discovering that she was her husband’s second wife. A few years later, her parents passed away, and her husband died accidentally, causing her pain from the memories of these lost loved ones and in relation to her own condition.

Mother 13: Sometimes I think about my parents , so I feel restless , that time it feels like I’m not able to take a breath , it feels like I’m not breathing , once I got senseless , I was very sick , my sister got to know about it , and she came and she took me to the hospital I: apart from your parent’s incident, is there anything else that makes you feel restless? Mother 13 : About my husband , the death of my husband , I think about it a lot , as we stayed together , now he is no more , I can also die , first my parents died , I was living with my parents , they died , then I was living with my husband , but he also died , I can also die . (…) Nowadays I am always thinking about my after-death situation .

Isolated woman.

Another woman, a widow who work as a maid and lives in a tin house, explained how she was surprised when the water level raised suddenly during cyclone Sitrang and described the stress she experienced due to the situation.

Mother 14: Yes , I was afraid , suddenly waterlogged inside the house and also inside the road , there was no one here , only 3–4 people were here whose stuff was here , I wasn’t able to organize anything .

The respondent was very tensed with exacerbated symptoms due to rumors in the slum about the occurrence of a new cyclone following Sitrang.

I: Still, you’re afraid because of this? Mother 14: Yes, people are saying that another cyclone is coming! I: So, you are feeling afraid? Mother 14 : Yes , I’m feeling afraid . I’m not going to work for 3–4 days . I can’t sleep , my body got wet , everything got wet . I got scared of seeing the water level , this is a problem !

Another respondent also exhibits symptoms of anxiety and has difficulty sleeping at night due to the fear of new cyclones. This fear and anticipation of potential disasters can exacerbate mental health issues, making it difficult for individuals to focus on their daily tasks and responsibilities. Mother 15 : Sometimes at midnight , like in the night-time , I feel scared , like maybe suddenly it can come , because I’m staying in the tong house because nowadays people are saying a new one is coming , so that’s why I’m afraid if it happened again then what I’ll do .

Pathways of cumulative effects on mental health: A case study

The following case is that of a woman who represents a typical example of the cumulative effects of environmental, economic, and negative feedback loops when climate events occur on the mental health. The negative feedback loop typically intertwines with economic strategies related to the household size, such as migration and early marriage, or in some cases, deciding which children will migrate to the city or stay in the village, and eventually planning to return home.

Trajectory of a woman from the coastal area and feeling trapped in the slum

This woman was born in a coastal area of Bangladesh, exposed to risks associated with climate events such as cyclones, river erosion, and slow-onset events (salinization). She belonged to a family of farmers who owned multiple lands for rice crops and vegetables and had two houses. During her childhood, she witnessed numerous cyclones and storms. In the early 2000s, a cyclone destroyed one of her family’s houses, but no one was injured. She occasionally suffered from nightmares involving storms destroying everything, especially when her area was flooded and waterlogged. Since the road was reconstructed and reduced waterlogging, she no longer suffers from nightmares.

In the mid-2000s, her family fell into poverty after river erosion destroyed their lands and houses. With six children, her father decided, for economic reasons, to marry his two older daughters to men from the capital, hoping for better living conditions. Her older sister moved to Dhaka and married a man from the slum through her uncle’s intervention. Later, her sister brought her to Dhaka and married her to her husband.

After her marriage, she discovered that her husband was addicted to marijuana and alcohol, spending significant amounts of money on drugs. Her husband worked as a rickshaw driver, earning about 5 USD every day. However, he sold his rickshaw six days before our visit. The couple has many expenses, including education fees for their two children in primary school (around 3 USD every month). They live in a semi-built house in the slum near the lake, paying an expensive rent of around 36 USD for one room. Food expenses for the whole family amount to around 90–110 USD.

Her husband’s drug addiction created conflicts within their marriage, and he often physically abused her. Her mother-in-law, aware of the situation, protected her son, leaving the woman feeling isolated. The Cyclone Sitrang exacerbated her stress, and she expressed "feeling very stressed with tension all the time" about her children’s future.

This case shows how the woman’s trajectory has been influenced by climate events, her family’s economic problems, and the decisions made to cope with these challenges, such as migration and early marriages. Moreover, it highlights how persistent issues, such as poverty, addiction, and family conflicts, can worsen a woman’s mental health situation, especially when she feels trapped and isolated. This case also demonstrates that women are often the most affected by the consequences of climate events and economic decisions made within their households.

Other respondents mentioned after the cyclone Sitrang their sadness about leaving a child in the village as a survival strategy in order to move to the city, only to realize they had fallen into a dead-end trap. These climatic events reawaken past pains and impact mental health by highlighting how their strategies have ultimately turned against them.

The lack of opportunity impacts all members of these communities, but it appears to be especially pronounced among women who shoulder caregiving responsibility, have limited access to education, and occupy the lowest positions within family hierarchies. Both acute and slow-onset events distinctly affect the mental health of women, mothers, and widows, as it is influenced by the interplay of socioeconomic factors, social networks, and environmental conditions. These intersecting factors intensify the vulnerabilities these women experience, making it even more difficult for them to cope with the consequences of climate-related events.

We emphasize the cumulative effects and the dynamics of both causal pathways (see Fig 1 ) to illustrate how they are reflected in a woman’s life trajectory, particularly as demonstrated in this case study. The Fig 2 portrays what we call a cumulative pathway at the individual level, to highlight what is often missing from the general framework: the interweaving of social, economic, and environmental factors throughout a woman’s life trajectory. These embedded factors are directly linked to her mental health outcomes, manifesting as anxiety and stress that are personal and specific to her experiences.

Fig 2 highlights the causal pathways where environmental events can act directly as precipitating factors of mental health outcomes or indirectly through socio-economic factors. At the individual level, rural or urban settings shaped trajectories but do not stand as independent factors due to the strategy of (im)mobility. Like Fig 1 , this diagram illustrates the trajectory of our case study, yet it does not represent all possible scenarios. Nevertheless, based on a longitudinal perspective, the cumulative pathway emerges as a recurring mechanism within our data, enabling the analysis of interactions and the concomitant effects of a variety of factors on the mental health of our respondents.

Specifically, the challenge is to demonstrate the dynamics of interactions at the individual level between collective socio-economic and environmental factors. This helps to complement frameworks that are most often based on epidemiological results, contributing to explanatory hypotheses. Our study sought to contribute to the overlooked aspect of the literature on how climate-related mental disorders are shaped throughout life in vulnerable communities in the Global South. The chosen approach is to demonstrate how women are disproportionately affected through two main mechanisms (see Fig 1 ): socioeconomic stressors and acute environmental events, that may be illustrated by the cumulative pathway ( Fig 2 ) at the individual level. Socioeconomic stressors, particularly during slow-onset environmental transformations, highlight the intersection between economic and environmental dimensions. Acute events directly cause psychological distress. The pathway, directly and indirectly related to climate change is well-established in the literature [ 3 ]. Our findings regarding acute events such as heat, and drought align with other studies that identify these events as mental health stressors with the potential to cause chronic stress [ 5 , 38 – 41 ].

In terms of causal mechanism, our results suggest that gender-related social status and roles shape individual trajectories in the context of climate change. They are key factors also found in other studies in the Global South [ 42 ]. Socioeconomic stressors appeared to be an intermediate factor. We specifically highlight that in these communities, economic survival strategies are based on the involvement of women in serving the household, which makes women’s health even more vulnerable during climate and environmental events. This exacerbates gender inequities and jeopardizes their mental health. Some studies have shown how gender violence is linked to climate events [ 42 ]. More specifically, in our research it appears that slow-onset events, exacerbated by their impact on livelihoods lead to household conflicts such as gender violence. This finding warrants further exploration and more generally we advocate for more studies conducted in the Global South and in the mid- long-term not only in the aftermath of extreme events. More broadly, our findings add to what has been established in terms of pathways on an international level [ 43 , 44 ], by providing insight into the longitudinal and cumulative aspects at the trajectory scale (see Fig 2 ). An additional dimension of our ethnographic work is to show how mental disorders are linked to the social, environmental, and economic histories of communities and are incorporated at the individual level, sometimes manifesting as vulnerabilities, particularly among women in the surveyed communities.

Furthermore, our study allows for an analysis of cumulative environmental, economic, and social events by examining individual trajectories, opening up new perspectives for mental health research in the Global South. This approach allows us to identify both the structural sociocultural factors and the individual psychological factors that shape a person’s mental health trajectory. It aligns with recent attempts to describe the causal process of mental health related to climate change examining how factors interact and influence one other [ 39 ].

The specificities of climate events are important to consider for the policy maker and in order to help the most vulnerable people. Usually, the main characteristics retained are the duration, frequency, intensity of an event, geographical location such as coastal areas [ 37 ]. Our results showed the difference in perception and experiences lived by the most vulnerable for an event considered as small-scale by the general authorities. While not of importance to the general population, it greatly affected both the living and economic conditions of a vulnerable community and their mental health. It is crucial for decision-makers to anticipate the impacts based on the topographic vulnerabilities of the sites and the individuals, in order to promote the establishment of shelters and the provision of material aid, even during less intense events such as Cyclone Sitrang. This situation is encountered by both men and women; however, it adds to gender-specific vulnerabilities [ 45 ] and should be taken into account to grasp the cumulative impact of vulnerabilities on individuals’ life trajectories.

Understanding the gender-specific vulnerabilities related to climate events is important to address the cumulative impact of vulnerabilities on individuals’ life trajectories. Mental health outcomes linked to SDGs will be difficult to achieve for women if the climate issue is not taken into account as it disproportionately affects women by reinforcing their vulnerabilities linked to social structures and producing new gender inequities.

More specific studies should be made in the Global South because the indirect impacts of climate change on mental health are mostly uncovered as it happened mostly in the rural setting. Yet, these countries are more vulnerable to climate events even if they are from far less responsible of the changing climate [ 46 ].

Our results highlight the importance for future research to consider psychological trajectories while taking into account health determinants, social factors, as well as environmental factors. This approach aims to better understand the mechanisms that affect populations and those shaping their resilience when they face several challenges. Our analysis confirms the research findings regarding the floods that occurred in Nigeria in 2011. Researchers found that this event impacted the childcare of women’s activities leading to increased anxiety about the health and safety of their children [ 47 ]. We also find in accordance with the literature various determinants that affect the link between mental health and climate change among women. Notably, one of the key factors is the socioeconomic status of women [ 42 ], which can exacerbate their vulnerability to the mental health impacts of climate change. Other determinants include gender roles and expectations, gendered violence [ 48 ], limited access to resources [ 49 ] and services after natural disasters [ 50 ], education, and the disproportionate burden of caregiving responsibilities [ 48 ]. These factors can contribute to increased stress, anxiety, psychological trauma and depression among women when faced with the challenges posed by climate change [ 14 ]. We demonstrate how the combination of factors such as socioeconomic status, gender roles, limited resources, and caregiving responsibilities can create a complex web of vulnerabilities that disproportionately affect women’s mental health in the face of climate change. By examining these interconnected factors in detail, we provide a more comprehensive understanding of the gendered impacts of climate change on mental health in vulnerable communities, thereby offering valuable insights for future research and policy interventions. Further research employing a trajectory-based approach is needed to better understand the interplay of factors and their contributions to the impacts of climate change on women’s mental health in vulnerable communities.

Limitations

Our study has limits. Our interviews were conducted in Bengali and transcribed so we might have lost a part of the information. However, the analysis was performed with the translator to overcome this risk. Our data were collected on a two-period basis, while this topic is a sensitive one and might need iterative interviews to build a greater trust from the respondents. We tried to overcome this limit by triangulating within the same household and meeting multiple time with our respondents to build a trusting relationship.

We were perceived as foreigners and outsiders which might have had an impact on the quality of data. During our initial fieldwork in the slum, we prioritized personal interviews over FGDs to foster relationships with residents. The context was challenging due to the residents’ economic struggles, limited availability, high expectations from us for immediate change, and interpersonal tensions between the residents. However, the relationship we established allowed us to conduct further individual interviews and one FGD with male local leaders during our second visit. In both settings we have been associated with their survival economic strategies and the interviews could have been biased to meet the respondent needs. The tools from the reflexive ethnography have helped us to analyze our position in each situation and how it has shaped the data.

Our study underscores the heightened vulnerability of women to the mental health impacts of climate change, particularly in relation to household strategies and the direct effects of climate events. Indeed, the burden of care intensifies with heat, while droughts affecting livelihoods result in increased workload and debt. Such situations contribute significantly to anxiety and symptoms associated with depression. Two primary causal factors impacting women’s mental health emerged from our study: socioeconomic stressors and acute events. These factors, when combined with social roles and family strategy, produce cumulative effects. Each determinant can either provide support or exacerbate negative mental health outcomes for women, who are deeply involved in coping strategies amidst the disruptions caused by environmental changes.

It is crucial to consider the specific mental health impacts of climate change on vulnerable groups, such as women, mothers, and widows, particularly in rural areas where resources and support may be limited. Providing access to mental health care, financial assistance, and climate-resilient livelihoods can help alleviate the strain on these individuals and improve their overall well-being.

Addressing the specific needs and vulnerabilities of women in the context of climate change requires a multi-faceted approach that includes promoting gender equality, empowering women to make informed decisions about their lives, and providing access to resources and support networks that can help them build resilience and cope with the challenges they face. Additionally, it is crucial to engage communities and stakeholders in the process of challenging and changing harmful gender norms and expectations that contribute to the vulnerability of women in the face of climate change.

Supporting information

S1 checklist. inclusivity in global research..

https://doi.org/10.1371/journal.pgph.0002080.s001

Acknowledgments

The authors acknowledge those who supported this work at various phases of our project and specifically all the participants in the two settings.

1. Pörtner HO, Roberts DC, Adams H, Adler C, Aldunce P, Ali E, et al. Climate change 2022: Impacts, adaptation and vulnerability. Geneva, Switzerland: IPCC; 2022.
2. Calvin K, Dasgupta D, Krinner G, Mukherji A, Thorne PW, Trisos C, et al. Climate Change 2023: Synthesis Report. Contribution of Working Groups I, II and III to the Sixth Assessment Report of the Intergovernmental Panel on Climate Change. [Internet]. First. Geneva, Switzerland: Intergovernmental Panel on Climate Change (IPCC); 2023 Jul [cited 2023 Oct 23] p. 35–115. (Lee H, Romero J, editors. Sections). Available from: https://www.ipcc.ch/report/ar6/syr/ .
View Article
PubMed/NCBI
Google Scholar
6. FAO. The White/Wiphala Paper on Indigenous Peoples’ Food Systems. Roma: FAO; 2021.
12. Denckla C, Koenen K, Kubzansky Lee Kum Kee L. Climate change and mental health: Developing a framework for interdisciplinary investigation [Internet]. Radcliffe Institute for Advanced Study at Harvard University. 2020 [cited 2022 Aug 5]. Available from: https://www.radcliffe.harvard.edu/opportunities-for-researchers/2021-exploratory-seminars/climate-change-and-mental-health-interdisciplinary-investigation .
14. Gender G, Alliance C. Gender and climate change: A closer look at existing evidence. New-York, USA: Global Gender and Climate Alliance: New York, NY, USA; 2016.
18. Eckstein D, Künzel V, Schäfer L, Winges M. Global climate risk index 2020. Bonn: Germanwatch. 2019.
20. Ahsan S, Ali MS, Hoque MR, Osman MS, Rahman M, Babar MJ, et al. Agricultural and Environmental Changes in Bangladesh in Response to Global Warming. In: Lal R, Sivakumar MVK, Faiz SMA, Mustafizur Rahman AHM, Islam KR, editors. Climate Change and Food Security in South Asia [Internet]. Dordrecht: Springer Netherlands; 2011 [cited 2023 Feb 12]. p. 119–34. Available from: https://doi.org/10.1007/978-90-481-9516-9_9 .
21. Brammer H. Climate change, sea-level rise and development in Bangladesh [Internet]. University Press; 2014 [cited 2022 Apr 13]. Available from: https://scholar.google.com/scholar_lookup?title=Climate+change%2C+sea-level+rise+and+development+in+Bangladesh&author=Brammer%2C+H.&publication_year=2014 .
23. National Institute of Mental Health. National Mental Health Survey of Bangladesh 2019 [Internet]. Dhaka, Bangladesh: NMIH; 2021 p. 187. Available from: http://nimh.gov.bd/wp-content/uploads/2021/11/Mental-Health-Survey-Report.pdf .
25. WHO. Bangladesh. WHO Special Initiative for Mental Health. Situational Assessment [Internet]. Geneva, Switzerland: WHO; 2020 p. 11. Available from: https://cdn.who.int/media/docs/default-source/mental-health/special-initiative/who-special-initiative-country-report—bangladesh—2020_f746e0ca-8099-4d00-b126-fa338a06ca6e.pdf?sfvrsn=c2122a0e_7 .
29. Davies CA. Reflexive ethnography: A guide to researching selves and others [Internet]. Routledge; 2008 [cited 2023 Oct 23]. Available from: https://books.google.fr/books?hl=en&lr=&id=WmYS4VGyzyUC&oi=fnd&pg=PP2&dq=reflexive+ethnography&ots=_PLwwwF-bQ&sig=rc8jDLIiLFNxinOgBdABUmpLaJo .
30. World Health Organization. Social determinants of mental health [Internet]. Geneva: World Health Organization; 2014 [cited 2022 Aug 30]. 52 p. Available from: https://apps.who.int/iris/handle/10665/112828 .
43. Lawrance DE, Thompson R, Fontana G, Jennings DN. The impact of climate change on mental health and emotional wellbeing: current evidence and implications for policy and practice. Imperial College; 2021.
44. WHO. Mental health and climate change: policy brief [Internet]. World Health Organization. Geneva: World Health Organization; 2022. 15 p. (Publications). Available from: https://apps.who.int/iris/bitstream/handle/10665/354104/9789240045125-eng.pdf?sequence=1&isAllowed=y .

This paper is in the following e-collection/theme issue:

Published on 25.6.2024 in Vol 10 (2024)

Ischemic Stroke After Bivalent COVID-19 Vaccination: Self-Controlled Case Series Study

Authors of this article:

Original Paper

Stanley Xu 1 , PhD ;
Lina S Sy 1 , MPH ;
Vennis Hong 1 , MPH ;
Kimberly J Holmquist 1 , MPH ;
Lei Qian 1 , PhD ;
Paddy Farrington 2 , PhD ;
Katia J Bruxvoort 3 , PhD ;
Nicola P Klein 4 , MD ;
Bruce Fireman 4 , MS ;
Bing Han 1 , PhD ;
Bruno J Lewin 1 , MD

1 Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, CA, United States

2 School of Mathematics and Statistics, The Open University, United Kingdom

3 Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States

4 Kaiser Permanente Vaccine Study Center, Kaiser Permanente Northern California, Oakland, CA, United States

Corresponding Author:

Stanley Xu, PhD

Department of Research & Evaluation

Southern California Permanente Medical Group

100 S Los Robles

Pasadena, CA, 91101

United States

Phone: 1 6265643958

Email: [email protected]

Background: The potential association between bivalent COVID-19 vaccination and ischemic stroke remains uncertain, despite several studies conducted thus far.

Objective: This study aimed to evaluate the risk of ischemic stroke following bivalent COVID-19 vaccination during the 2022-2023 season.

Methods: A self-controlled case series study was conducted among members aged 12 years and older who experienced ischemic stroke between September 1, 2022, and March 31, 2023, in a large health care system. Ischemic strokes were identified using International Classification of Diseases, Tenth Revision codes in emergency departments and inpatient settings. Exposures were Pfizer-BioNTech or Moderna bivalent COVID-19 vaccination. Risk intervals were prespecified as 1-21 days and 1-42 days after bivalent vaccination; all non–risk-interval person-time served as the control interval. The incidence of ischemic stroke was compared in the risk interval and control interval using conditional Poisson regression. We conducted overall and subgroup analyses by age, history of SARS-CoV-2 infection, and coadministration of influenza vaccine. When an elevated risk was detected, we performed a chart review of ischemic strokes and analyzed the risk of chart-confirmed ischemic stroke.

Results: With 4933 ischemic stroke events, we found no increased risk within the 21-day risk interval for the 2 vaccines and by subgroups. However, risk of ischemic stroke was elevated within the 42-day risk interval among individuals aged younger than 65 years with coadministration of Pfizer-BioNTech bivalent and influenza vaccines on the same day; the relative incidence (RI) was 2.13 (95% CI 1.01-4.46). Among those who also had a history of SARS-CoV-2 infection, the RI was 3.94 (95% CI 1.10-14.16). After chart review, the RIs were 2.34 (95% CI 0.97-5.65) and 4.27 (95% CI 0.97-18.85), respectively. Among individuals aged younger than 65 years who received Moderna bivalent vaccine and had a history of SARS-CoV-2 infection, the RI was 2.62 (95% CI 1.13-6.03) before chart review and 2.24 (95% CI 0.78-6.47) after chart review. Stratified analyses by sex did not show a significantly increased risk of ischemic stroke after bivalent vaccination.

Conclusions: While the point estimate for the risk of chart-confirmed ischemic stroke was elevated in a risk interval of 1-42 days among individuals younger than 65 years with coadministration of Pfizer-BioNTech bivalent and influenza vaccines on the same day and among individuals younger than 65 years who received Moderna bivalent vaccine and had a history of SARS-CoV-2 infection, the risk was not statistically significant. The potential association between bivalent vaccination and ischemic stroke in the 1-42–day analysis warrants further investigation among individuals younger than 65 years with influenza vaccine coadministration and prior SARS-CoV-2 infection. Furthermore, the findings on ischemic stroke risk after bivalent COVID-19 vaccination underscore the need to evaluate monovalent COVID-19 vaccine safety during the 2023-2024 season.

Introduction

On August 31, 2022, the US Food and Drug Administration (FDA) granted emergency use authorizations for the Pfizer-BioNTech bivalent COVID-19 vaccine for individuals aged 12 years and older and the Moderna bivalent COVID-19 vaccine for individuals aged 18 years and older [ 1 , 2 ]. The bivalent vaccines contain messenger ribonucleic acid (mRNA) components derived from both the original strain of SARS-CoV-2 and the Omicron variant BA.4 and BA.5 sublineages. Designed to be administered as a single booster dose, bivalent COVID-19 vaccines were recommended to be given ≥60 days after either the primary vaccination or a monovalent booster dose [ 2 ]. In the context of waning protection from primary vaccination, bivalent vaccines enhanced the immune response and boosted protection against the virus, offering an additional layer of defense for previously vaccinated individuals [ 3 - 5 ].

Safety data for bivalent mRNA COVID-19 vaccines were initially limited. Because the chemical components and production processes between monovalent and bivalent vaccines were similar, the FDA granted emergency use authorizations for the bivalent COVID-19 vaccines based on safety data for monovalent vaccines, as well as limited bivalent safety data from clinical trials [ 1 , 2 ]. To monitor safety postlicensure, a study using V-safe and the Vaccine Adverse Event Reporting System (VAERS) examined bivalent booster vaccinations in individuals aged older than or equal to 12 years and found that the safety profile was similar to that described for monovalent booster vaccinations [ 6 ]. A recent study that comprehensively assessed potential adverse events associated with bivalent vaccines using TreeScan in the Vaccine Safety Datalink (VSD) network found no increased risk for a broad range of adverse events [ 7 ].

The VSD has monitored COVID-19 vaccine safety since vaccinations began in December 2020 [ 8 ]. In late 2022, VSD’s rapid cycle analyses detected a safety signal for ischemic stroke following the Pfizer-BioNTech COVID-19 bivalent booster vaccination among those 65 years and older, particularly among those who had received a bivalent booster dose and a high-dose or adjuvanted influenza vaccine on the same day (coadministration) [ 9 ]. The US Centers for Disease Control and Prevention (CDC) and FDA announced this safety signal in January 2023 [ 10 ]. This safety signal attenuated as data accumulated [ 11 ]. Another cohort study among adults aged 65 years and older reported that those who received the Pfizer-BioNTech bivalent booster had a similar hazard for ischemic stroke encounters compared to those who received the Moderna bivalent booster vaccine, but had a lower hazard than those who received the Pfizer-BioNTech or Moderna monovalent boosters [ 12 ]. In another study, compared to monovalent vaccination, bivalent vaccination was not found to be associated with an increased risk of ischemic stroke, hemorrhagic stroke, myocardial infarction, and pulmonary embolism [ 13 ]. A self-controlled case series (SCCS) study conducted in England showed no indication of an increased risk of ischemic stroke risk within 21 days following administration of either of the 2 mRNA COVID-19 bivalent vaccines. Similar findings were observed for individuals aged 65 years and older who received the influenza vaccine concurrently with the bivalent COVID-19 vaccines [ 14 ]. Another SCCS study conducted in Israel also did not find an increased risk of ischemic stroke following monovalent or bivalent mRNA COVID-19 vaccine boosters in at-risk populations [ 15 ]. A study of Medicare beneficiaries aged 65 years or older showed no significantly elevated risk for stroke immediately after receiving either COVID-19 bivalent vaccine [ 16 ]. However, among beneficiaries who had a stroke after getting either COVID-19 bivalent vaccine along with a high-dose or adjuvanted influenza vaccine, there was a significant association between vaccination and nonhemorrhagic stroke within 22 to 42 days for the Pfizer-BioNTech COVID-19 bivalent vaccine. Additionally, there was a significant association between vaccination and transient ischemic attack within 1 to 21 days for the Moderna COVID-19 bivalent vaccine.

The objective of this study was to assess the risk of ischemic stroke after bivalent COVID-19 vaccination among individuals enrolled in Kaiser Permanente Southern California (KPSC) using a modified SCCS design. Subgroup analyses were also conducted by age (younger than 65 years vs older than or equal to 65 years), history of SARS-CoV-2 infection, and coadministration of influenza vaccine.

Study Population and Study Period

We conducted an SCCS study among members aged 12 years and older from KPSC, a large integrated health care system in the United States. The SCCS method is an alternative to standard epidemiological study designs and has been used for evaluating vaccine safety and in fields such as pharmacoepidemiology [ 17 - 21 ]. In an SCCS study, only individuals who have experienced an event are included. Since individuals serve as their own control and the incidence rates of the outcome of interest are compared within individuals, all time-invariant confounding variables are controlled. The SCCS analytic data sets included individuals who experienced ischemic stroke events between September 1, 2022, and March 31, 2023, had completed a COVID-19 vaccine primary series, and had received their last monovalent dose ≥60 days before September 1, 2022. We required KPSC membership on September 1, 2022.

Exposure and Observation Period

The exposure was defined as the administration of the Pfizer-BioNTech bivalent COVID-19 vaccine (for individuals aged 12 years and older ) or the Moderna bivalent COVID-19 vaccine (for individuals aged 18 years and older) between September 1, 2022, and March 31, 2023. The observation period for the recipients of a bivalent COVID-19 vaccine started on September 1, 2022, and ended on March 31, 2023, or upon death, receipt of the second bivalent dose, or disenrollment, whichever came first.

To adjust for seasonality, we also included ischemic stroke events occurring among eligible individuals aged 12 years and older who had completed a primary series and had received their last monovalent dose ≥60 days before September 1, 2022, but who did not receive a bivalent vaccine during September 1, 2022, to March 31, 2023 (nonbivalent recipients; NBRs). The observation period for ischemic stroke events among NBR started on September 1, 2022, and ended on March 31, 2023, or upon death or disenrollment, whichever came first.

The outcome was defined as the first occurrence of an ischemic stroke event between September 1, 2022, and March 31, 2023 [ 22 ]. Ischemic stroke events were identified through medical encounters with an International Classification of Diseases, Tenth Revision ( ICD-10 ) diagnosis code of G45.8, G45.9, or I63.x, where x represents any additional characters in the ICD-10 code range for ischemic stroke, in the emergency departments or inpatient settings. We also looked back 30 days prior to September 1, 2022, to ensure that the episode was incident. We excluded ischemic stroke events due to other possible causes and adjusted the onset date (details in Multimedia Appendix 1 ). We considered these ischemic stroke events that were identified with ICD-10 codes to be electronically identified ischemic stroke events.

We collected demographic variables (age, sex, and race or ethnicity) and the Charlson Comorbidity Index to describe the characteristics of the study population, as well as concomitant influenza vaccination during the study period and history of SARS-CoV-2 infection in the year prior to September 1, 2022.

Statistical Analyses

We assessed the risk of ischemic stroke following the administration of the Pfizer-BioNTech and Moderna bivalent COVID-19 vaccines separately. Demographic characteristics of individuals who experienced ischemic stroke events during the study period were described among Pfizer-BioNTech bivalent vaccine recipients, Moderna bivalent vaccine recipients, and NBRs.

The risk intervals were prespecified as 1-21 days and 1-42 days after administration of bivalent COVID-19 vaccines, with person-time outside of these risk intervals serving as the control interval. The risk intervals started on the day of vaccination (day 1). Because individuals who had ischemic stroke events might be likely to postpone or avoid bivalent vaccination, we used a modified SCCS approach for event-dependent exposures [ 22 ]. The modified SCCS used a pseudo-likelihood approach in the counterfactual framework to estimate the relative incidence (RI) and 95% CIs of events comparing the risk intervals to their corresponding control intervals by maximizing a Poisson pseudolikelihood [ 23 ]. In the SCCS analyses, ischemic stroke events occurring among eligible individuals who did not receive the bivalent vaccines were included to account for seasonality, by incorporating calendar month into the model [ 22 ]. Given that age did not significantly vary during the relatively short observation period of 7 months, it was not adjusted as a time-varying covariate.

Additionally, we performed several subgroup analyses based on age (younger than 65 vs 65 years and older), coadministration of bivalent COVID-19 vaccine with same-day influenza vaccine (yes or no), and history of SARS-CoV-2 infection (confirmed by a positive laboratory test or a COVID-19 diagnosis) within 1 year prior to September 1, 2022.

When a safety signal (ie, the lower bound of the 95% CI for RI exceeded 1.0) was detected in analyses of electronically identified ischemic stroke events, we conducted a chart review among recipients of bivalent COVID-19 vaccines to confirm ischemic stroke events and identify onset date to determine whether confirmed ischemic stroke events fell in the risk or control interval; confirmation rates were then calculated (number of confirmed events divided by the number of electronically identified events reviewed). We did not conduct a chart review on ischemic stroke events among NBR due to the large number of events in this group and limited resources. In analyses of confirmed ischemic stroke events among recipients of bivalent COVID-19 vaccines, we introduced a randomized allocation of confirmed case status to the NBR group. This allocation was guided by the confirmation rates observed among recipients of bivalent COVID-19 vaccines, as outlined by Xu et al [ 24 ]. A total of 5 simulated data sets were generated to replicate the allocation process. The SCCS analyses were conducted on each data set, and the resulting estimates were aggregated using Rubin’s [ 25 ] rule, which accounts for both the variability within individual data sets and the variability across multiple data sets. Attributable risk (AR) was calculated using the approach described in Farrington et al [ 26 ]:

Here, RI is the relative incidence; n R is the number of ischemic stroke events in the risk interval; and N is the number of recipients of a vaccine or dose. The reciprocal of AR is the number needed to harm (NNH). Analyses were conducted using SAS (version 9.4; SAS Institute) and the SCCS models were fitted with the R package (R Core Team) SCCS [ 27 ].

Ethical Considerations

Ethics approval for this study was obtained from the KPSC institutional review board on June 6, 2023. In accordance with 45CFR 46.116, informed consent was waived by the institutional review board because the research activities (secondary analyses of electronic health records data) presented no more than minimal risk to participants. Patients or members of the public were not involved in the design, conduct, reporting, or dissemination plans of the research. To protect the privacy and confidentiality of human participants, all staff working on the research study were trained in procedures to protect the privacy of medical record information. All research data were stored behind a firewall in a password-protected network within the Department of Research & Evaluation at KPSC. Study participants were not compensated given the observational nature of the study.

Characteristics of Individuals Who Had Ischemic Stroke Events

Table 1 shows the characteristics of individuals who had ischemic stroke events. In total, there were 1057 ischemic stroke events among recipients of the Pfizer-BioNTech bivalent vaccine with a mean length of observation period of 204 (SD 27) days (ranging from 16 to 212 days), 827 ischemic stroke events among recipients of the Moderna bivalent vaccine with a mean length of observation period of 206 (SD 24) days (ranging from 31 to 212 days), and 3049 ischemic stroke events among NBR with a mean length of observation period of 197 (SD 40) days (ranging from 11 to 212 days). Notably, the majority of ischemic stroke events occurred among individuals aged 65 years or older. Those aged younger than 65 years old had fewer comorbidities than those aged 65 years or older ( Multimedia Appendix 2 ).

			Recipients of Pfizer-BioNTech bivalent COVID-19 vaccine (n=1057)		Recipients of Moderna bivalent COVID-19 vaccine (n=827)		Nonrecipients of bivalent vaccines (n=3049)

	12-17	1 (0.1)		N/A		6 (0.2)
	18-44	32 (3.0)		15 (1.8)		261 (8.6)
	45-64	245 (23.2)		177 (21.4)		1011 (33.2)
	65-74	618 (58.5)		501 (60.6)		1406 (46.1)
	≥75	161 (15.2)		134 (16.2)		365 (12.0)

	Female	540 (51.1)		446 (53.9)		1637 (53.7)
	Male	517 (48.9)		381 (46.1)		1412 (46.3)

	Hispanic	311 (29.4)		259 (31.3)		1186 (38.9)
	Non-Hispanic White	470 (44.5)		326 (39.4)		1027 (33.7)
	Non-Hispanic Asian	119 (11.3)		99 (12.0)		270 (8.9)
	Non-Hispanic Black	139 (13.1)		120 (14.5)		472 (15.5)
	Missing	6 (0.6)		9 (1.1)		37 (1.2)
	Multiple or other	12 (1.1)		14 (1.7)		57 (1.9)
Length of observation period in days, mean (SD)			204.3 (26.8)		205.7 (23.5)		196.7 (39.9)
Death, n (%)			50 (4.7)		37 (4.5)		309 (10.1)

a N/A: not applicable.

Risk of Ischemic Stroke Following the Pfizer-BioNTech Bivalent COVID-19 Vaccine

For the Pfizer-BioNTech bivalent COVID-19 vaccine, there were 103 electronically identified ischemic stroke events in the 21-day postvaccination risk interval, 954 events in the control interval, and 3049 events among NBR; the overall RI was 0.90 (95% CI 0.73-1.12; Multimedia Appendix 3 ). The RI was not significantly above 1 across all subgroup analyses by age, coadministration of influenza vaccine, and history of SARS-CoV-2 infection.

In analyses extending the risk interval to 1-42 days following bivalent vaccination, the overall RI was 0.97 (95% CI 0.81-1.15; Table 2 ). However, in subgroup analyses using the 1-42–day risk interval, we observed an increased risk of ischemic stroke only among individuals younger than 65 years of age who also received an influenza vaccine on the same day. The RI in this subgroup was 2.13 (95% CI 1.01-4.46). Among the subset who also had a documented history of SARS-CoV-2 infection within the year preceding the study period, the RI increased to 3.94 (95% CI 1.10-14.16).

In this 1-42–day risk interval analysis of the specific subgroup of individuals aged younger than 65 years who received bivalent and influenza vaccines on the same day, chart review of the 37 electronically identified ischemic stroke events found that 2 were determined to be hemorrhagic strokes and 11 were subsequently found to not meet the criteria for true ischemic stroke events, yielding a confirmation rate of 65% (n=24). With the verified 24 ischemic stroke events and ischemic stroke events among NBR (not verified through chart review, but adjusted for using a 65% confirmation rate), we proceeded to reevaluate the RI in this subgroup. The number of confirmed ischemic stroke events was graphed over the interval in days between bivalent vaccination and ischemic stroke event ( Figure 1 ). There were 10 events in the 1-42–day risk interval and 14 events in the control interval. Using a risk interval of 1-42 days after coadministration of the Pfizer-BioNTech bivalent vaccine and influenza vaccine, the overall RI derived from analyzing confirmed ischemic stroke events among those aged younger than 65 years was 2.34 (95% CI 0.97-5.65; P =.06; Table 3 ). Between September 1, 2022, and March 31, 2023, a total of 117,423 individuals aged younger than 65 years received the Pfizer-BioNTech bivalent vaccine and influenza vaccine on the same day. According to the equation, AR=4.88×10 –5 and NNH=20,505 with a risk interval of 1-42 days. Among 21,128 individuals who also had a documented history of SARS-CoV-2 infection within the year preceding the study period, the RI increased to 4.27 (95% CI 0.97-18.85; P =.06; Table 3 ); according to the equation, AR=1.45×10 –4 and NNH=6897 with a risk interval of 1-42 days. Among the 10 confirmed ischemic stroke events in the risk interval of 1-42 days, the mean age was 58 (SD 5) years, ranging from 48 to 63 years. Among these cases, 2 individuals had a documented history of previous ischemic stroke, and no one died as of March 31, 2023. In addition, 7 received the standard dose, egg-based quadrivalent influenza vaccine, while 3 received an influenza vaccine of unknown formulation.

	All ages						<65 years old						≥65 years old
	Number of events, n				Relative incidence (95% CI)		Number of events, n				Relative incidence (95% CI)		Number of events, n				Relative incidence (95% CI)
	Risk interval	Control interval	NBRs			Risk interval		Control interval	NBRs			Risk interval		Control interval	NBRs

Overall	212	845	3049	0.97 (0.81-1.15)		50		228	1278	0.98 (0.69-1.38)		162		617	1771	0.96 (0.79-1.17)
With history of SARS-CoV-2	35	139	565	0.98 (0.66-1.47)		15		53	292	1.22 (0.64-2.33)		20		86	273	0.83 (0.50-1.40)
Without history of SARS-CoV-2	177	706	2484	0.97 (0.80-1.17)		35		175	986	0.91 (0.61-1.38)		142		531	1498	0.99 (0.80-1.22)

Overall	41	126	3049	0.97 (0.66-1.41)		15		22	1278	2.13 (1.01-4.46)		26		104	1771	0.75 (0.47-1.19)
With history of SARS-CoV-2	9	20	565	1.26 (0.56-2.82)		6		4	292	3.94 (1.10-14.16)		3		16	273	0.51 (0.14-1.90)
Without history of SARS-CoV-2	32	106	2484	0.91 (0.59-1.40)		9		18	986	1.57 (0.61-4.05)		23		88	1498	0.80 (0.49-1.31)

Overall	171	719	3049	0.96 (0.80-1.17)		35		206	1278	0.81 (0.54-1.20)		136		513	1771	1.01 (0.81-1.25)
With history of SARS-CoV-2	26	119	565	0.89 (0.56-1.40)		9		49	292	0.82 (0.37-1.80)		17		70	273	0.88 (0.50-1.55)
Without history of SARS-CoV-2	145	600	2484	0.99 (0.80-1.22)		26		157	986	0.82 (0.52-1.29)		119		443	1498	1.04 (0.82-1.31)

a NBR: nonbivalent recipient. These were eligible individuals who did not receive a bivalent vaccine but had completed a primary series of COVID-19 vaccination and had their last monovalent dose ≥60 days before September 1, 2022. Inclusion of these events helps to adjust for temporal trends (seasonality). The same NBR population was used in overall bivalent analyses, as well as bivalent analyses stratified by coadministration of influenza vaccine.

b Had SARS-CoV-2 infection (ie, SARS-CoV-2 positive laboratory test or a COVID-19 diagnosis) during the year prior (August 31, 2021-August 31, 2022).

	Number of events, n				Relative incidence (95% CI)
	Risk interval	Control interval	NBRs
Overall	10	14	835	2.34 (0.97-5.65)
With history of SARS-CoV-2	4	3	190	4.27 (0.97-18.85)
Without history of SARS-CoV-2	6	11	645	1.76 (0.57-5.45)

a Confirmation by chart review.

b NBR: nonbivalent recipient. These were eligible individuals who did not receive a bivalent vaccine but had completed a primary series of COVID-19 vaccination and had their last monovalent dose ≥60 days before September 1, 2022. Inclusion of these events helps to adjust for temporal trends (seasonality). A confirmation rate of 65% was applied to ischemic stroke events among NBR.

c Had SARS-CoV-2 infection (ie, SARS-CoV-2 positive laboratory test or a COVID-19 diagnosis) during the year prior (August 31, 2021-August 31, 2022).

Risk of Ischemic Stroke Following the Moderna Bivalent COVID-19 Vaccine

When using a risk interval of 21 days following Moderna bivalent vaccination, the overall risk of ischemic stroke was not elevated from the analysis of electronically identified ischemic stroke events (RI=0.91, 95% CI 0.71-1.15), a finding that held true across all subgroup analyses by age, coadministration of influenza vaccine, and history of SARS-CoV-2 infection ( Multimedia Appendix 4 ). However, extending the risk interval to 42 days after Moderna bivalent vaccination showed an increased risk of ischemic stroke among individuals younger than 65 years of age who had a documented history of SARS-CoV-2 infection, with an RI of 2.62 (95% CI 1.13-6.03). This subgroup involved a total of 36 ischemic stroke events among recipients of the Moderna bivalent COVID-19 vaccine ( Table 4 ).

Of the 36 ischemic stroke events, 1 was a hemorrhagic stroke and 12 were not confirmed as true events through medical chart review, yielding a confirmation rate of 64% (n=23). After using a risk interval of 1-42 days following the Moderna bivalent vaccination and applying a 64% confirmation rate to ischemic stroke events among NBR, the RI derived from analyzing confirmed ischemic stroke events among those aged younger than 65 years who had a documented history of SARS-CoV-2 infection was 2.24 (95% CI 0.78-6.47; P =.14).

	All ages						<65 years old						≥65 years old
	Number of events, n				Relative incidence (95% CI)		Number of events, n				Relative incidence (95% CI)		Number of events, n				Relative incidence (95% CI)
	Risk interval	Control interval	NBRs			Risk interval		Control interval	NBRs			Risk interval		Control interval	NBRs

Overall	161	666	3049	0.92 (0.76-1.12)		34		158	1278	0.99 (0.64-1.53)		127		508	1771	0.90 (0.72-1.13)
With history of SARS-CoV-2	28	111	565	1.02 (0.66-1.59)		10		26	292	2.62 (1.13-6.03)		18		85	273	0.71 (0.42-1.19)
Without history of SARS-CoV-2	133	555	2484	0.90 (0.72-1.12)		24		132	986	0.73 (0.43-1.23)		109		423	1498	0.95 (0.74-1.21)

Overall	19	72	3049	0.80 (0.45-1.43)		8		20	1278	1.42 (0.59-3.43)		11		52	1771	0.60 (0.28-1.29)
With history of SARS-CoV-2	3	14	565	0.59 (0.15-2.30)		3		4	292	2.43 (0.54-10.87)		0		10	273	N/A
Without history of SARS-CoV-2	16	58	2484	0.85 (0.45-1.63)		5		16	986	1.05 (0.36-3.08)		11		42	1498	0.80 (0.36-1.76)

Overall	142	594	3049	0.94 (0.76-1.16)		26		138	1278	0.89 (0.54-1.47)		116		456	1771	0.95 (0.75-1.19)
With history of SARS-CoV-2	25	97	565	1.11 (0.69-1.76)		7		22	292	2.69 (0.98-7.36)		18		75	273	0.83 (0.49-1.42)
Without history of SARS-CoV-2	117	497	2484	0.91 (0.71-1.15)		19		116	986	0.67 (0.37-1.21)		98		381	1498	0.97 (0.75-1.26)

c N/A: not applicable.

Sex-Stratified Analyses

Further analyses were conducted to examine if the risk of ischemic stroke after bivalent vaccination differed by sex for those analyses indicating a potential increase in risk of ischemic stroke ( Multimedia Appendix 5 ). The risk of ischemic stroke was not significantly increased after bivalent vaccination in the sex-stratified analyses. Due to limited sample sizes, the CIs of RIs were wide. The SAS and R codes are available for preparing data and fitting the event-dependent SCCS models ( Multimedia Appendix 6 ).

Principal Findings

These SCCS analyses did not find evidence that the risk of ischemic stroke was elevated during the 1-21–day postvaccination risk interval in both overall and subgroup analyses by age (younger than 65 years vs 65 years or older), prior history of SARS-CoV-2 infection, and coadministration of influenza vaccine, for both Pfizer-BioNTech and Moderna bivalent vaccines. However, based on electronically identified events, the risk of ischemic stroke was increased within the 1-42–day window after vaccination among those aged younger than 65 years who received their Pfizer-BioNTech bivalent vaccine and influenza vaccine on the same day; the risk was even higher among those who also had a documented SARS-CoV-2 infection history. After conducting a chart review of ischemic stroke events, the point estimate for the risk of ischemic stroke was still elevated in a risk interval of 1-42 days for these 2 subgroup analyses but did not meet the threshold for statistical significance ( P =.06).

For Moderna bivalent vaccination, an initial increase in the risk of ischemic stroke emerged within the 1-42–day window after vaccination among those aged younger than 65 years who had a documented SARS-CoV-2 infection history. However, after conducting a chart review of ischemic stroke events, the RI was 2.24 but was no longer statistically significantly elevated possibly due to a decreased sample size ( P =.14).

Our study showed an increased point estimate for the risk of ischemic stroke in a risk interval of 1-42 days only among those aged younger than 65 years who received their Pfizer-BioNTech bivalent vaccine and influenza vaccine on the same day, although not statistically significant. This finding is unique and may be attributed to differences in the study design compared to previous studies. First, our study used a calendar-based observation period spanning from September 1, 2022, to March 31, 2023. This extended timeframe enabled us to use a longer risk window of 1-42 days following vaccination in addition to the risk interval of 1-21 days in previous studies. Second, we did not exclude individuals with a history of ischemic stroke, but we did apply criteria to increase the likelihood that ischemic stroke events during the study period represented a new ischemic stroke episode. Nevertheless, it is possible that there was interaction between bivalent vaccination and a history of ischemic stroke. Furthermore, in subgroup analyses, we considered the influence of the history of SARS-CoV-2 infection. SARS-CoV-2 infection is associated with an increased risk of ischemic stroke [ 28 , 29 ] and risk factors for SARS-CoV-2 infection may overlap with risk factors for ischemic stroke. There is a potential interaction between bivalent vaccination and a history of SARS-CoV-2 infection. The finding that the point estimate for the risk of ischemic stroke was elevated among individuals aged younger than 65 years but not among individuals aged 65 years or older is also biologically plausible. This may be due to the relatively heightened immune response and subsequent inflammation in the younger age group versus the older age group, and the fact that inflammation has been shown to be associated with an increased risk of ischemic stroke [ 30 , 31 ]. Moreover, a smaller proportion of younger adults opted for bivalent vaccination [ 32 ], and those who did might have had a higher prevalence of comorbidities or poorer overall health status.

Limitations and Strengths

This study had several limitations. First, the study took place in a single health care system. Additionally, the number of ischemic stroke events in individuals with a documented SARS-CoV-2 infection history who received coadministration of Pfizer-BioNTech bivalent vaccine and influenza vaccine was very small. This raises concerns about the validity of the asymptotic large sample assumptions that underlie both the 95% CIs and P values. Second, we did not conduct a chart review of ischemic stroke events among NBR; these events contributed to establishing baseline rates of ischemic stroke events during the study period. In addressing this issue, when analyzing chart-confirmed ischemic stroke events among recipients of bivalent vaccine, we applied the confirmation rate of ischemic stroke events among recipients of bivalent vaccine to ischemic stroke events among NBR. Moreover, we also did not undertake a chart review of ischemic stroke events from those analyses when safety signals were absent. Third, while we excluded ischemic stroke events occurring within 30 days of SARS-CoV-2 infection, it is possible that some ischemic stroke events included in the analyses involved individuals with asymptomatic or mild COVID-19 disease who did not have a documented SARS-CoV-2 infection. Fourth, the elevated point estimate for the risk of ischemic stroke, while not statistically significant, was observed within the 1-42–day period following the coadministration of the Pfizer-BioNTech bivalent vaccine and influenza vaccine. This risk interval was longer than the 1-21 days or 1-28 days investigated in earlier research [ 10 , 13 , 33 ]. However, the biological plausibility for the occurrence of a vaccine-related ischemic stroke beyond 28 days remains uncertain. Fifth, unaccounted time-varying confounders could have also influenced the findings. Finally, our analysis did not adjust for multiple subgroup analyses by age, coadministration of bivalent COVID-19 vaccine and influenza vaccine, and history of SARS-CoV-2 infection. These specific subgroup analyses were prespecified due to their potential safety concerns. The decision not to make multiple comparison adjustments was deliberate, aimed at ensuring that any potential vaccine safety concern could be detected.

The study also had several strengths. First, we addressed the impact of previous ischemic stroke events on bivalent COVID-19 vaccination by using an event-dependent modified SCCS design. Second, we explored effect heterogeneity by conducting subgroup analyses based on factors such as age, documented history of SARS-CoV-2 infection, and coadministration of influenza vaccine. Third, to adjust for temporal trends, we included ischemic stroke events among NBR. This strategy not only enhanced the accuracy of estimating the baseline rate but also improved the statistical power for identifying potential safety signals. Finally, we reanalyzed ischemic stroke events that were confirmed through chart review for those analyses where safety signals were detected.

Future research should include several key aspects to further enhance the validity and robustness of our findings. Collaborative efforts with additional health care systems will enable us to significantly increase our sample size. A larger sample size could provide sufficient statistical power to conduct sensitivity analyses such as the exclusion of transient ischemic attacks and exclusion of those who had a history of ischemic stroke.

In light of the findings of this study on the risk of ischemic stroke after bivalent COVID-19 vaccination, it is necessary to assess the safety of the monovalent COVID-19 vaccination during 2023-2024 for several reasons. First, while the bivalent COVID-19 vaccines included 2 components (BA.4 and BA.5), the monovalent COVID-19 vaccines during the 2023-2024 season included 1 component (XBB.1.5). This change in vaccine composition warrants continued surveillance to assess any differential safety profiles. Second, during the 2023-2024 season, coadministration of monovalent COVID-19 vaccine and influenza vaccine on the same day was possible given the timing of availability of both products and the recommendation by the CDC.

Conclusions

We found no evidence to suggest that the Pfizer-BioNTech bivalent vaccine increased the risk of ischemic stroke among individuals aged older than 65 years, consistent with the attenuated signal from the VSD surveillance that motivated this study. We found an elevated point estimate for the risk of ischemic stroke within 1-42 days (but not within 1-21 days) after the coadministration of the Pfizer-BioNTech bivalent vaccine and influenza vaccine among individuals younger than 65 years old that did not reach statistical significance, although the sample size was limited. Future studies with a larger sample size are needed to evaluate the association between bivalent COVID-19 vaccination and ischemic stroke, as well as contributing factors such as the history of SARS-CoV-2 infection. Any potential risks of ischemic stroke associated with bivalent COVID-19 vaccination must be balanced against the potential benefits of bivalent COVID-19 vaccination in preventing COVID-19–associated ischemic stroke and severe COVID-19 disease.

Acknowledgments

Funding for this study was provided by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health (R01 AI168209). The National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the paper; and decision to submit the paper for publication. The findings and conclusions in this report are those of the authors and do not necessarily represent the official views of the National Institutes of Health. Kaiser Permanente Southern California stroke chart abstractions from the Vaccine Safety Datalink were used in this work. Kristin Goddard and Pat Ross from Kaiser Permanente Northern California and Kayla Hanson from Marshfield Clinic Research Institute developed the stroke chart abstraction forms. The authors thank the Kaiser Permanente Southern California chart abstractors Jose Pio and Julliane Bacerdo.

Data Availability

The data sets generated and analyzed during this study are not publicly available due to potentially identifying or sensitive patient information but are available from the corresponding author on reasonable request.

Conflicts of Interest

LSS reports research support from Moderna for a COVID-19 vaccine effectiveness study and GlaxoSmithKline, Dynavax, and Moderna for unrelated studies. LQ reports research support from Moderna, GlaxoSmithKline, and Dynavax for unrelated studies. KJB reports research support from Moderna, Pfizer, GlaxoSmithKline, and Dynavax for unrelated studies. NPK reports research support from Pfizer for COVID-19 vaccine clinical trials and unrelated research support from Pfizer, GlaxoSmithKline, Merck, and Sanofi Pasteur.

Definition of electronically identified ischemic strokes.

Descriptive statistics of Charlson Comorbidity Index by vaccine type and age (<65 years old and ≥65 years old) among members of Kaiser Permanente Southern California who had ischemic stroke events during the period from September 1, 2022, to March 31, 2023.

Numbers of electronically identified ischemic stroke events and relative incidences in the 21 days after Pfizer-BioNTech bivalent COVID-19 vaccination among members of Kaiser Permanente Southern California during the period from September 1, 2022, to March 31, 2023.

Numbers of electronically identified ischemic stroke events and relative incidences in the 21 days after Moderna bivalent COVID-19 vaccination among members of Kaiser Permanente Southern California during the period from September 1, 2022, to March 31, 2023.

Stratified analyses by sex for those analyses that signaled using electronically identified ischemic stroke events: numbers of confirmed ischemic stroke events and relative incidences in the 42 days after bivalent vaccination among members of Kaiser Permanente Southern California aged <65 years during the period from September 1, 2022, to March 31, 2023.

SAS and R codes for preparing data and fitting the dependent SCCS models.

Coronavirus (COVID-19) update: FDA authorizes changes to simplify use of bivalent mRNA COVID-19 vaccines. U.S. Food and Drug Administration. URL: https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update -fda-authorizes-moderna-pfizer-biontech-bivalent-covid-19-vaccines-use [accessed 2023-07-10]
Rosenblum HG, Wallace M, Godfrey M, Roper LE, Hall E, Fleming-Dutra KE, et al. Interim recommendations from the advisory committee on immunization practices for the use of bivalent booster doses of Covid-19 vaccines - United States, october 2022. MMWR Morb Mortal Wkly Rep. 2022;71(45):1436-1441. [ FREE Full text ] [ CrossRef ] [ Medline ]
Chalkias S, Harper C, Vrbicky K, Walsh SR, Essink B, Brosz A, et al. A bivalent omicron-containing booster vaccine against Covid-19. N Engl J Med. 2022;387(14):1279-1291. [ FREE Full text ] [ CrossRef ] [ Medline ]
Davis-Gardner ME, Lai L, Wali B, Samaha H, Solis D, Lee M, et al. Neutralization against BA.2.75.2, BQ.1.1, and XBB from mRNA bivalent booster. N Engl J Med. 2023;388(2):183-185. [ FREE Full text ] [ CrossRef ] [ Medline ]
Zou J, Kurhade C, Patel S, Kitchin N, Tompkins K, Cutler M, et al. Neutralization of BA.4–BA.5, BA.4.6, BA.2.75.2, BQ.1.1, and XBB.1 with bivalent vaccine. N Engl J Med. 2023;388(9):854-857. [ CrossRef ] [ Medline ]
Hause AM, Marquez P, Zhang B, Myers TR, Gee J, Su JR, et al. Safety monitoring of bivalent Covid-19 mRNA vaccine booster doses among persons aged =12 years - United States, August 31-October 23, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(44):1401-1406. [ FREE Full text ] [ CrossRef ] [ Medline ]
Katherine Yih W, Daley MF, Duffy J, Fireman B, McClure DL, Nelson JC, et al. Safety signal identification for COVID-19 bivalent booster vaccination using tree-based scan statistics in the Vaccine Safety Datalink. Vaccine. 2023;41(36):5265-5270. [ CrossRef ] [ Medline ]
Klein NP, Lewis N, Goddard K, Fireman B, Zerbo O, Hanson KE, et al. Surveillance for adverse events after Covid-19 mRNA vaccination. JAMA. 2021;326(14):1390-1399. [ FREE Full text ] [ CrossRef ] [ Medline ]
COVID-19 mRNA bivalent booster vaccine safety. US Centers for Disease Control and Prevention. URL: https://www.fda .gov/media/164811/download [accessed 2023-09-01]
CDC and FDA identify preliminary COVID-19 vaccine safety signal for persons aged 65 years and older. U.S. Food and Drug Administration. URL: https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/cdc-and-fda-identify -preliminary-covid-19-vaccine-safety-signal-persons-aged-65-years-and-older [accessed 2023-08-01]
Shimabukuro TT. mRNA COVID-19 bivalent booster vaccine safety update. US Centers for Disease Control and Prevention. URL: https://stacks.cdc.gov/view/cdc/127294 [accessed 2023-08-10]
Gorenflo M, Davis P, Kaelber D, Xu R. Ischemic stroke after COVID-19 bivalent vaccine administration in patients aged 65 years and older in the United States. NPJ Vaccines. Nov 23, 2023;8:180. [ FREE Full text ] [ CrossRef ]
Jabagi M, Bertrand M, Botton J, Le Vu S, Weill A, Dray-Spira R, et al. Stroke, myocardial infarction, and pulmonary embolism after bivalent booster. N Engl J Med. 2023;388(15):1431-1432. [ FREE Full text ] [ CrossRef ] [ Medline ]
Andrews N, Stowe J, Miller E, Ramsay M. BA.1 bivalent Covid-19 vaccine use and stroke in England. JAMA. 2023;330(2):184-185. [ FREE Full text ] [ CrossRef ] [ Medline ]
Yamin D, Yechezkel M, Arbel R, Beckenstein T, Sergienko R, Duskin-Bitan H, et al. Safety of monovalent and bivalent BNT162b2 mRNA Covid-19 vaccine boosters in at-risk populations in Israel: a large-scale, retrospective, self-controlled case series study. Lancet Infect Dis. 2023;23(10):1130-1142. [ CrossRef ] [ Medline ]
Lu Y, Matuska K, Nadimpalli G, Ma Y, Duma N, Zhang HT, et al. Stroke risk after Covid-19 bivalent vaccination among US older adults. JAMA. 2024;331(11):938-950. [ CrossRef ] [ Medline ]
Farrington CP. Relative incidence estimation from case series for vaccine safety evaluation. Biometrics. 1995;51(1):228-235. [ CrossRef ] [ Medline ]
Whitaker HJ, Farrington CP, Spiessens B, Musonda P. Tutorial in biostatistics: the self-controlled case series method. Stat Med. 2006;25(10):1768-1797. [ CrossRef ] [ Medline ]
Glanz JM, McClure DL, Xu S, Hambidge SJ, Lee M, Kolczak MS, et al. Four different study designs to evaluate vaccine safety were equally validated with contrasting limitations. J Clin Epidemiol. 2006;59(8):808-818. [ CrossRef ] [ Medline ]
Petersen I, Douglas I, Whitaker H. Self controlled case series methods: an alternative to standard epidemiological study designs. BMJ. 2016;354:i4515. [ FREE Full text ] [ CrossRef ] [ Medline ]
Xu S, Sy LS, Hong V, Farrington P, Glenn SC, Ryan DS, et al. Mortality risk after Covid-19 vaccination: a self-controlled case series study. Vaccine. 2024;42(7):1731-1737. [ FREE Full text ] [ CrossRef ] [ Medline ]
Ghebremichael-Weldeselassie Y, Jabagi MJ, Botton J, Bertrand M, Baricault B, Drouin J, et al. A modified self-controlled case series method for event-dependent exposures and high event-related mortality, with application to COVID-19 vaccine safety. Stat Med. 2022;41(10):1735-1750. [ FREE Full text ] [ CrossRef ] [ Medline ]
Farrington C, Whitaker H, Hocine M. Case series analysis for censored, perturbed, or curtailed post-event exposures. Biostatistics. 2009;10(1):3-16. [ CrossRef ] [ Medline ]
Xu S, Clarke CL, Newcomer SR, Daley MF, Glanz JM. Analyzing self-controlled case series data when case confirmation rates are estimated from an internal validation sample. Biom J. 2018;60(4):748-760. [ FREE Full text ] [ CrossRef ] [ Medline ]
Rubin DB. Multiple Imputation for Nonresponse in Surveys. New York. John Wiley and Sons; 2004.
Farrington P, Whitaker H, Ghebremichael-Weldeselassie Y. Self-Controlled Event Series Studies: A Modelling Guide With R. Boca Raton, FL. Chapman & Hall/CRC Press; 2018.
Ghebremichael-Weldeselassie Y, Whitaker H, Farrington P. SCCS: the self-controlled case series method. CRAN R Project. URL: https://CRAN.R-project.org/package=SCCS [accessed 2023-01-13]
Merkler AE, Parikh NS, Mir S, Gupta A, Kamel H, Lin E, et al. Risk of ischemic stroke in patients with coronavirus disease 2019 (Covid-19) vs patients with influenza. JAMA Neurol. 2020;77(11):1366-1372. [ FREE Full text ] [ CrossRef ] [ Medline ]
Yang Q, Tong X, George MG, Chang A, Merritt RK. Covid-19 and risk of acute ischemic stroke among medicare beneficiaries aged 65 years or older: self-controlled case series study. Neurology. 2022;98(8):e778-e789. [ FREE Full text ] [ CrossRef ] [ Medline ]
Jin R, Yang G, Li G. Inflammatory mechanisms in ischemic stroke: role of inflammatory cells. J Leukoc Biol. 2010;87(5):779-789. [ FREE Full text ] [ CrossRef ] [ Medline ]
Brockman M, Mwimanzi F, Lapointe H, Sang Y, Agafitei O, Cheung PK, et al. Reduced magnitude and durability of humoral immune responses to Covid-19 mRNA vaccines among older adults. J Infect Dis. 2022;225(7):1129-1140. [ FREE Full text ] [ CrossRef ] [ Medline ]
COVID Data Tracker. US Centers for Disease Control and Prevention. URL: https://covid.cdc.gov/covid-data-tracker/#vac cinations_vacc-people-booster-percent-total [accessed 2023-08-22]
Ihle-Hansen H, Bøås H, Tapia G, Hagberg G, Ihle-Hansen H, Berild JD, et al. Stroke after SARS-CoV-2 mRNA vaccine: a nationwide registry study. Stroke. 2023;54(5):e190-e193. [ FREE Full text ] [ CrossRef ] [ Medline ]

Abbreviations

attributable risk

US Centers for Disease Control and Prevention

US Food and Drug Administration

International Classification of Diseases, Tenth Revision

Kaiser Permanente Southern California

messenger ribonucleic acid

nonbivalent recipient

number needed to harm

relative incidence

self-controlled case series

Vaccine Adverse Event Reporting System

Vaccine Safety Datalink

Edited by A Mavragani, T Sanchez; submitted 19.10.23; peer-reviewed by M Jabagi, T Tong, T Cerqueira-Silva; comments to author 09.04.24; accepted 21.05.24; published 25.06.24.

©Stanley Xu, Lina S Sy, Vennis Hong, Kimberly J Holmquist, Lei Qian, Paddy Farrington, Katia J Bruxvoort, Nicola P Klein, Bruce Fireman, Bing Han, Bruno J Lewin. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 25.06.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Public Health and Surveillance, is properly cited. The complete bibliographic information, a link to the original publication on https://publichealth.jmir.org, as well as this copyright and license information must be included.

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Public Health Ethics: Global Cases, Practice, and Context

Open Access
First Online: 13 April 2016

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Leonard W. Ortmann Ph.D. 8 ,
Drue H. Barrett Ph.D. 8 ,
Carla Saenz Ph.D. 9 ,
Ruth Gaare Bernheim J.D., M.P.H. 10 ,
Angus Dawson Ph.D. 11 ,
Jo A. Valentine M.S.W. 12 &
Andreas Reis M.D., M.Sc. 13

Part of the book series: Public Health Ethics Analysis ((PHES,volume 3))

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The opinions, findings, and conclusions of the authors do not necessarily reflect the official position, views, or policies of the editors, the editors’ host institutions, or the authors’ host institutions.

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Public Health

Locating Public Health Ethics

Virtue Ethic
Ethical Theory
Health Equity
Ethical Challenge
Clinical Ethic

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

1 Introduction

Introducing public health ethics poses two special challenges. First, it is a relatively new field that combines public health and practical ethics . Its unfamiliarity requires considerable explanation, yet its scope and emergent qualities make delineation difficult. Moreover, while the early development of public health ethics occurred in a Western context, its reach, like public health itself, has become global. A second challenge, then, is to articulate an approach specific enough to provide clear guidance yet sufficiently flexible and encompassing to adapt to global contexts. Broadly speaking, public health ethics helps guide practical decisions affecting population or community health based on scientific evidence and in accordance with accepted values and standards of right and wrong. In these ways, public health ethics builds on its parent disciplines of public health and ethics. This dual inheritance plays out in the definition the U.S. Centers for Disease Control and Prevention (CDC) offers of public health ethics: “A systematic process to clarify, prioritize , and justify possible courses of public health action based on ethical principles , values and beliefs of stakeholders , and scientific and other information ” (CDC 2011 ). Public health ethics shares with other fields of practical and professional ethics both the general theories of ethics and a common store of ethical principles, values , and beliefs. It differs from these other fields largely in the nature of challenges that public health officials typically encounter and in the ethical frameworks it employs to address these challenges. Frameworks provide methodical approaches or procedures that tailor general ethical theories, principles , values, and beliefs to the specific ethical challenges that arise in a particular field. Although no framework is definitive, many are useful, and some are especially effective in particular contexts. This chapter will conclude by setting forth a straightforward, stepwise ethics framework that provides a tool for analyzing the cases in this volume and, more importantly, one that public health practitioners have found useful in a range of contexts. For a public health practitioner, knowing how to employ an ethics framework to address a range of ethical challenges in public health—a know-how that depends on practice—is the ultimate take-home message.

We learn new things more readily when we can relate them to familiar things, and we understand complex things by breaking them into their components. Accordingly, throughout this introductory chapter, we will relate public health ethics to more familiar concepts and better-known related fields, while the immediately following section will explore the components of public health ethics that derive from its parent disciplines of public health and ethics. After describing public health’s core activities, goals, and values , we will explain why ethical concepts like the right to health , social justice , and health equity directly follow as central concerns of public health. After defining ethics broadly in everyday terms, we will examine the complementary roles facts and values play in public health. This examination is important because the respective bases of the two parent disciplines differ considerably; public health science rests on the logic of scientific discovery, whereas ethics rests on the logic of right action and good decision making. We will then contrast the more familiar, everyday understanding of morality with the formal discipline of ethics as a prelude to considering three well-known ethical theories relevant to public health. Because both laws and ethical rules establish parameters for public health practice, their similarity and difference need to be clarified. This extended account, first of parent disciplines, then of kindred concepts, and finally of family resemblances between the related fields of clinical ethics , bioethics , and research ethics , will culminate in an effort to characterize what is distinctive about public health ethics.

2 Public Health

There are many definitions of public health. They often begin as descriptions of current practice but once established become prescriptions for subsequent practice. It is important, then, to consider definitions, because they shape not only public health practice, but also how we conceive of public health ethics (Dawson and Verweij 2007 ). The same logic applies to how we think about the individual concepts of health and the public. Defining health as the absence of disease or symptoms, for example, more readily fits allopathic medicine, which focuses on negating symptoms to treat disease. But it hardly fits public health’s emphasis on preventive measures that address root causes rather than symptoms. Nor does it cover public health’s promotion of health and well-being across a range of interventions. In this regard, the World Health Organization (WHO) offers a definition of health more suitable to public health: “A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO 2006 ). But even this more holistic definition does not sufficiently clarify the meaning of “public” in public health. Dawson and Verweij ( 2007 ) identify two primary meanings of “public” in public health, each of which they break down into three senses. Public can mean population-wide and refer to (1) the epidemiologically measured health of a population or group, (2) the distribution of health in a population, or (3) the underlying social and environmental conditions impacting everyone’s health. Public also can mean collectively accomplished and requiring (1) the concerted actions of many people and institutions whether governmental or nongovernmental; (2) the cooperation or involvement of the public, or (3) the public’s joint participation to realize the health improvement.

In a practical field like public health, definition often takes the form of enumerating key activities, such as surveillance , sanitation , maintaining food and workplace safety , disease prevention and control , and promoting healthy behavior. The identification of the ten essential services of public health illustrates this enumerative approach (Fig. 1.1 ) (Public Health Functions Steering Committee 1994 ). These services fall under three overarching functions of assessment, policy development, and assurance that constitute an integrated cyclic process. The delivery of these services in local, regional, or national public health agencies accordingly defines public health practice. In this schema, research is a distinct practical service but also integral to all public health activities, providing insights and innovative solutions at every point. Public health ethics addresses the entire spectrum of ethical issues that arise in any area of public health practice but especially in those areas where no specific guidelines govern practice.

Essential Public Health Services . (1) Monitor health status to identify community health problems. (2) Diagnose and investigate health problems and health hazards in the community. (3) Inform, educate, and empower people about health issues. (4) Mobilize community partnerships and action to identify and solve health problems. (5) Develop policies and plans that support individual and community health efforts. (6) Enforce laws and regulations that protect health and ensure safety . (7) Link people to needed personal health services and assure the provision of health care when otherwise unavailable. (8) Assure competent public and personal health care workforce. (9) Evaluate effectiveness , accessibility, and quality of personal and population-based health services. (10) Research for new insights and innovative solutions to health problems (From Public Health Functions Steering Committee 1994 . Essential Public Health Services . Available at http://www.cdc.gov/nphpsp/essentialServices.html )

Such lists have the advantage of concretely specifying current activities but lack criteria that definitions normally provide for including or excluding additional activities as a field develops. In 1920, Charles Edward A. Winslow, an influential public health theorist and leader, pioneered a definition of public health that still informs many European and international public health institutions, including WHO (Marks et al. 2011 ).

Public health is the science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts … and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health (Winslow 1920 ).

Even more succinctly, the U.S. Institute of Medicine (IOM) defines public health as “what we, as a society, do collectively to assure the conditions for people to be healthy” (IOM 1988 ).

These two definitions highlight the importance of collective action to address the health needs of populations . Public health’s population focus distinguishes it from clinical medicine’s focus on individual patients, though examples like vaccination indicate that the two fields can overlap. Epidemiologists statistically aggregate the health data of individuals to provide a picture of population health , but populations ultimately originate from communities of individuals who constitute social wholes. Individuals in society stand in complex relations of interdependence , competition, and solidarity that can impact health in ways that transcend the individual. Thus, in addition to aggregating individual medical data, epidemiologists need to measure the impact of various social factors on health. To tackle the complex, often competing health needs of social groups, public health practitioners need to dialogue and partner with their communities. At a higher administrative level, public health officials need to manage intersectoral collaborations , navigate political processes, and formulate public health law. Four distinguishing features of public health practice—the pursuit of the collective good, a focus on prevention , the use of government or collective action, and an emphasis on an outcome-based (utilitarian) approach—generate most of the ethical challenges public health practitioners typically face (Faden and Shebaya 2010 ).

2.1 Core Values

People value many things such as friends and family, material goods and resources, knowledge, and art. Some things people value are ethical virtues like courage or honesty, whereas others are ethical principles like justice and equality. People generally value what they consider important, what matters to them, and what gives their lives meaning. Public health’s primary goals and commitments reflect its core values, which are rooted in health, science, and the community (Public Health Leadership Society 2002 ). Everyone recognizes the value of health, but public health approaches health in relation to science and the community in its endeavor to prevent disease and injury, protect the public from harm, and promote health and well-being. But seeing how science and community represent values requires a word of explanation.

The commitment to science as a value stance often becomes apparent only in relation to people who distrust science or prioritize other value commitments such as economic interests or religion. Public health values science by endeavoring to base interventions and policies on the best available data and evidence-based practices. That endeavor entails a commitment to conduct surveillance and research , because only by understanding the social burden of disease and its underlying or structural causes can public health impact the health of the entire population . The qualifier “best available” is a reminder of the need to continuously improve practice and not rely on tradition or current practices. It also reminds us that during emergencies, time and resource constraints limit the ability to gather evidence.

Public health values community in two obvious senses. First, it recognizes that the success of most health interventions depends on a community’s acceptance, cooperation, or participation . Second, it recognizes that to be successful, public health must respect the community’s values and gain the trust of its members. Yet there is a third, deeper sense in which community represents a value. A community is, to emphasize again, neither a statistical abstraction nor a mere aggregate of individuals but rather a network of relationships and emotional bonds between people sharing a life in common organized through a political and moral order (Jennings 2007 ). The value that best reflects this fundamental, relational character of social life is solidarity . Solidarity can remain unspoken yet operative because it forms the basis of social life and collective action. Just as communities are not mere aggregates of individuals, neither are the agencies or organizations that make the collective decisions that affect the community. Personal interests, to be sure, can motivate individuals, but the felt recognition of a common plight, that we are all in it together, underlies the collective decisions society and public health must make to solve collective problems. To say that public health values community means that it values solidarity, even when solidarity remains unacknowledged as is often the case (Dawson and Jennings 2012 ).

2.2 Health Equity , Social Justice, and Social Determinants of Health

As the foregoing goals, definitions, core values , and commitments of public health clearly suggest, the right to health and health equity are central, not peripheral, to public health’s mission. Chapter 8 on international collaboration will examine some practical challenges in addressing the right to health and social determinants of health, so the emphasis here will be on the rationale for achieving health equity as a matter of social justice.

Despite greater individual access to health care and advances in public health, high burdens of disease remain across much of the globe. Some differences in disease burden result from genetics and some from variable risks of exposure to infectious agents and other threats, but most of the differential burden arises from social, economic, and political conditions . These conditions include poverty, lack of education, and discrimination against particular social groups and often reflect historical injustices or long-standing systemic, structural deficiencies. Collectively, these conditions have come to be known as social determinants of health (Blane 1999 ). Greater access to individual health care can mitigate their effect, but an adequate response to them requires concerted public action to address their underlying causes.

Whether comparing countries or groups within countries, social stratification by social determinants correlates with differences in health status (Marmot 2007 ). These health differences have aroused widespread concern, but how one defines them significantly affects public health practice (Braveman 2006 ). In particular, distinguishing health disparity from health inequity is critical. As a comparative indicator of health status, health disparity is a neutral, epidemiologic term that need not imply an ethical obligation to remedy. Health disparities , however, can and frequently do reflect underlying inequities. WHO defines health inequities as health differences that are “socially produced; systematic in their distribution across the population ; and unfair” (WHO 2007 ). Terms like “inequity” and “unfair” are ethical terms that imply an obligation to redress an injustice. Justice has a range of meanings that include giving people what they deserve or are owed and distributing goods and services fairly. Justice in a medical context often involves the individual’s access to health services. In public health, discussions of health equity usually involve questions of how to distribute health benefits fairly or how to achieve better health outcomes among communities or groups that suffer health inequities . Attaining greater equity might involve the politically controversial strategy of disproportionally distributing resources within a population , by, for example, distributing more to those most in need. A less-controversial strategy is to improve health outcomes for all, even while devoting special efforts to those most in need. WHO defines health equity as “the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically, or geographically” (WHO 2007 ).

Achieving health equity is most urgent for groups who have experienced histories of marginalization and discrimination and who continue to experience higher rates of illness and premature deaths than members of the mainstream population . Especially for these groups, “social injustice is killing people on a grand scale” (WHO 2008 ). Realizing the goal of social justice with respect to health means achieving health equity. Doing so requires not only a fair distribution of health outcomes , it also means that “ideally everyone should have a fair opportunity to attain their full health potential” and that “no one should be disadvantaged from achieving this potential, if it can be avoided” (Whitehead 1992 ). For many, these goals imply that social justice obligates public health to improve any social condition that prevents people from maintaining a standard of life adequate to maintain health (Powers and Faden 2006 ). Although some believe that improving social conditions that affect health overextends public health’s mandate, such a broad mandate is arguably consistent with both Winslow’s and IOM’s definitions of public health. Moreover, such a broad mandate has both nineteenth century precursors in the social medicine movement and more recent precedents in the “Health for All” strategy that emphasizes health promotion and the “Health in All Policies” strategy (Kickbusch 2003 ; Freiler et al. 2013 ). But a major milestone was reached with the 2008 report of the WHO Commission on Social Determinants of Health that sought to “marshal the evidence on what can be done to promote health equity , and to foster a global movement to achieve it” (WHO 2008 ). and essential services, establish policies that provide an equitable basis for health improvement, and gather and monitor data on health equity , achieving equity ultimately will depend on the cooperation of government and civil society (Blas et al. 2008 ).

People strive to be “good,” to do the “right” thing and to lead a “good life,” but where do such basic, familiar moral values as good and right originate? Throughout history, religious people have explained these ideas as revelations of divine command. Anthropologists, however, view morals as customs that govern social interactions, and because all cultures display such customs, interpret moral practices in terms of a survival function rooted in human nature. By contrast, many social and political thinkers emphasize that moral concepts result from social conventions or agreements that are subject to deliberation and change. Governments today often consult social scientists and health experts who empirically investigate what fosters or improves human life, health, and happiness. Where science informs law and policy , it helps define in a conventional sense what we mean by good and right. In particular, public health science helps establish what is considered good for the health of populations and communities. Further below we will examine three ethical theories prominent in public health ethics that offer contrasting perspectives on the nature and basis of morality . In the meantime, we will address three general questions that a public health practitioner first approaching the study of ethics might well ask: how does science relate to ethics, what is the difference between ethics and mora lity, and what sort of things count as principles or basic concepts in ethics?

3.1 Scientific Facts and Ethical Values

Public health practice increasingly requires appreciation of the complementary roles facts and values play in making and justifying decisions. Observation reveals facts, while scientific research controls and manipulates the experimental context to discover causation or correlation. Data on disease burden , research on intervention effectiveness , and estimates of the resultant health benefits for the population generally inform public health interventions . Health messaging can often inform the public about the scientific rationale underlying public health interventions. Nevertheless, in the mind of the public, scientific evidence does not always invalidate or outweigh other sources of evidence or appeals to emotions, interests, and values. While public health practitioners give more weight to community health and scientific evidence, they also need to consider how the public will respond to an intervention. Successfully implementing public health actions, then, will often entail weighing the public’s attitudes, interests, and values in relation to public health’s core values.

Two mundane features of public health practice often serve to conceal value assumptions: shared core values and standard practice. First, sharing values can render them invisible as assumptions, until they unexpectedly become contested. Unwelcome surprises occur when interventions that presuppose core values affect stakeholders who do not share those values, as when parents refuse to have children vaccinated based on media hearsay or individuals reject a highly effective program as governmental intrusion. Avoiding such surprises begins with becoming aware of one’s own value presuppositions in relation to those of other stakeholders and community members. Second, routine use of evidence-based standards can conceal underlying value assumptions. If developed and tested to address a known health problem, as is common, an intervention’s purpose and effectiveness is taken for granted. Standard interventions, then, generally require no more justification than noting their standard status or seeing that “the facts dictated” their use. “Dictating” facts are indicators that trigger use of a standard intervention (e.g., meeting the criteria of a case definition or documenting exposure to a dangerous level of a contaminant). Such “dictating facts,” more properly speaking, only indicate the appropriate intervention but cannot literally dictate that anything be done. What in the end dictate actions are the values, goals, and obligations that the standard intervention presupposes and that practitioners tacitly ratify each time they apply the standard. In other words, values, goals, and obligations , even when tacit, form a necessary bridge between knowledge and action.

Though standard practices tacitly incorporate ethical principles , they seldom raise ethical challenges. Challenges more typically arise in unusual or extreme situations where standards are not yet in place, are changing, or are competing. These situations include emergency operations, foreign cultural settings, emergent fields with innovative interventions, or periods of severe budget constraints that force prioritization of programs. In such challenging situations where no value consensus exists or where evidence does not point to a single course of action, public health ethics provides a process to determine and justify a course of action. That justification can incorporate a number of factors: evidence base for the intervention, cost effectiveness , analysis of relevant ethical rules and stakeholder values , a creative design of options or alternatives that embody these values, and a fair and transparent decision-making process that incorporates stakeholder contributions.

Recognizing one’s own value assumptions in relation to those of the public will be critical for implementing new interventions wherever success depends on public acceptance. The public will not embrace interventions that embody or presuppose values that clash with community values or whose relative importance is low compared to other community values. Members of the public generally are more committed to their political views, ethical and religious values, and an intervention’s impact on them personally than to scientific evidence or community impact. Public health practitioners need to recognize that no matter how compelling to them, community impact and scientific rationale seldom resonate as deeply with the public. Consequently, in communicating, public health practitioners need to supplement scientific messaging with dialogue, an appeal to common values, or enlistment of spokespersons who share the value orientation of the relevant stakeholder s or community. Regarding some controversial matters, ultimate success in implementing an intervention may require building a social consensus (Ortmann and Iskander 2013 ).

In certain situations, untangling factual claims based on science from value judgments is critical for success. For example, suppose independent investigators have scientifically verified the level of worker exposure to a toxic chemical used in industry. Determining what level of exposure would be safe, however, remains a value judgment that depends on the degree of concern that people have about safety . Placing a higher value on safety might result in stricter controls that decrease risk for workers, but the financial costs of decreasing risks could cut industry profits or jobs, even as health costs fall. Stakeholders representing industry, workers, or public health practitioners might have different positions regarding a safe level of exposure. To make a good decision about a safe exposure level, the value of safety might have to be discussed and weighed in relation to business, employment, and health considerations. However, these varying positions regarding safety need not imply disregard for safety or disagreement on the underlying facts. Rather, they illustrate that conflicting value judgments can coexist despite a consensus on both the underlying facts and the importance of a particular value such as safety .

Directly addressing the value conflicts in such situations through ethical deliberation makes more sense than calling into question the underlying facts and can lead to better, fairer, and more transparent decisions. It is also important to recognize that doubting the science often represents an underlying value dispute masquerading as a scientific dispute (Brunk et al. 1991 ). Sowing doubt on scientific assessments merely as a tactic to oppose an evidence-based policy or recommendation undermines science. This doubt can exert pressure to test and retest results, raising the bar for scientific validity ever higher (Michaels 2008 ). The solution is not to litigate, as it were, the science, but to recognize that communicating risk is a social process that goes beyond science messaging and must take cultural attitudes, perceptions, and symbolic meanings into account (Krimsky and Plough 1988 ). Where profound value disagreements prevail, public health legitimately prioritizes its core values but cannot speak for everyone. Stakeholder views require a fair hearing, whether through media research , stakeholder analysis, or direct solicitation of input from individuals, focus groups, or public meetings. By design, a fair, transparent ethical decision-making procedure can help determine what value tradeoffs are feasible and what values may be nonnegotiable. Such a deliberative procedure can help to gain public acceptance and become part of the justification for a course of action.

To those accustomed to rigorous research methods and evidence-based standards of practice, navigating the world of ethical values and rules can be perplexing. Values, as the term itself implies, manifest valences, that is, variable degrees of commitment or estimations of importance along a continuum. Individuals rank values differently, change their rankings, and will alter their relative ranking of values in different contexts. The range of options for ethical rules are far more limited, namely, to obey or not obey. Nevertheless, the ethical rules governing particular situations also vary from country to country or even from jurisdiction to jurisdiction within a country. Despite this variability in values and ethical rules, reducing ethical judgment to mere opinion or to a consensus of opinion relative only to personal or cultural preferences would be a mistake. Ethical values and rules enjoy the approval of history, custom, law , and religious tradition, but they also find anchor biologically, psychologically, and socially in human life. Value judgments and ethical determinations, then, are not relative as much as correlative; that is, they correlate and resonate with these deeper roots of human life that we share. If humans indeed share a set of fundamental values, then ethical conflicts primarily reflect differences in prioritizing values in a particular context, rather than a fundamental disagreement about values. This point of view provides grounds for optimism about the possibility of finding a deeper basis for understanding and mutual respect , if not agreement, when ethical tensions surface.

3.2 Ethics and Morality

Although many use the terms ethics and morality interchangeably, we will distinguish the formal discipline of ethics from the common morality that guides everyday actions and behavior. Morality refers to a society’s shared, stable beliefs about what is good and bad, right and wrong. Through upbringing and socialization, each generation passes this common morality to the next. Common morality envelopes the individual like an ecosphere of shared customs, rules, and values . For most circumstances, people habitually rely on this common morality to guide their conduct, and it serves them well, just as standard practice generally serves professional practitioners well. Still, common morality can fall short where its rules conflict , where it inadequately illuminates novel moral problems, or where intense disagreement prevails among rival stakeholder s. In such instances, the formal discipline of ethics offers a deliberate, systematic way of addressing troubling moral issues, conflicts , and dilemmas . Ethics can assist in:

Recognizing ethical issues and distinguishing them from factual issues;

Providing a vocabulary to systematically discuss ethics;

Identifying appropriate ethical principles to guide action in a particular context;

Using these principles to analyze actions in regard to their ethical acceptability;

Understanding the competing moral claims and values of stakeholders ;

Designing alternative courses of action that incorporate these claims and values;

Evaluating which alternative best fits a given context, all things considered

Establishing a procedurally just, transparent process for decision making; and

Justifying decisions regarding recommendations, policies, or intervention s.

3.3 Ethical Principles

Principles are general categories, rules, or guidelines that form the basis of a discipline. In ethics, there are various kinds of principles and many examples of each kind. The kinds include basic ethical categories (e.g., virtues, values , or rights), ethical commands or rules of conduct (e.g., not stealing, not harming, or treating others with respect ), and guidelines for weighing outcomes (e.g., achieving the greatest good for the greatest number, distributing burdens and benefits fairly, or properly proportioning benefit to harm). Ethical principles like justice or respect for autonomy are simultaneously values, ideals, and the basis for deriving rules of conduct. Such rules serve as ethical standards to evaluate past and pending actions, programs, and policy recommendations . When addressing complex or controversial issues or issues involving numerous stakeholders , many different principles can come into play. But because ethical decision making depends on context (e.g., on local circumstances, community stakeholders, and decision makers), no formula can determine the most relevant ethical principles. Nevertheless, most ethicists and practitioners working in a field would agree that certain principles, theories, or frameworks provide more helpful guidance for that field. Given the need for flexibility, some prefer to speak not of ethical principles but of “general moral considerations” that can provide guidance in public health practice (Childress et al. 2002 ). At any rate, a complex ethical challenge involving stakeholders with competing moral claims frequently demands consideration of a variety of ethical principles and theories to address the situation and justify a proposed intervention. For these reasons, it will be useful both to examine below several ethical theories used in public health ethics and to provide at the end of the chapter a framework that is generally applicable to ethical issues that arise in public health.

3.4 Ethical Theories

As used here, an ethical framework refers to a tool or approach for practically addressing ethical challenges that often includes a stepwise procedure. An ethical framework may rely heavily on just one ethical theory, but frameworks generally take a pragmatic approach that procedurally allows for using a variety of theories or principles as the issue or context demands. Whereas an ethical framework has a practical orientation, an ethical theory also addresses more fundamental questions, so-called “metaethical” questions. Does morality originate in divine command, human nature, or human convention? Is it essentially a habit, intuition, form of reasoning, or a quality or purpose of an action? An ethical theory will offer a distinct, coherent understanding of the source and nature of morality that will shape how one reasons about moral issues and determine which principles are most important. Two persons employing the same theory, however, will not necessarily reach the same conclusion about an ethical issue; much will depend on which aspects of the issue they deem most important and on how they weigh different factors. Nevertheless, because a particular ethical theory tends to favor certain principles or types of principles, using the same theoretical approach will lead to similar lines of reasoning and selection of principles .

The diversity of ethical theories does not imply their mutual opposition so much as points to the extensive range of the moral landscape and the need to illuminate its various contours. A helpful way of illuminating this landscape is to distinguish theories depending on whether they focus on the actor, the action, or the results of action. To illustrate this particular way of carving up the moral landscape, Table 1.1 describes some well-known ethical theories.

Aristotle’s virtue ethics is an ethical theory that focuses on the moral character of the actor or agent (Bartlett and Collins 2011 ). Classic virtues are dispositions or stable patterns of behavior that lie between extremes of vice; courage, for example, lies between the extremes of cowardice and foolhardiness in taking risks. Habit and practice are necessary to develop virtues whose possession we equate with good character and that equip a person to be effective in society or an organization. Because good character translates into virtuous action that others aspire to emulate, we tacitly invoke virtue ethics whenever we ask how an outstanding public figure or health leader would handle a situation. In a modern professional context, virtues also include the skills the profession has identified that lead to success in that profession and which professional education and training instill in practitioners. Once established, virtues readily become the standards of obligation and accountability to evaluate professional performance and function similarly to the rules and principles of duty discussed below. Holding public health institutions accountable for the professional competence of their employees illustrates virtue ethics (Public Health leadership Society 2002 ). More recently, th e capabilities approach has exploited the potential of virtue ethics to guide decisions about policy or interventions in a way that goes beyond matters of professional training and responsibilities. This approach takes a broader developmental view of human agency and capacity building. It conceives health as a fundamental capability necessary for individuals to succeed in society, one on which many further capabilities depend (Sen 2009 ; Ruger 2010 ).

An ethical theory that focuses on action or, more properly, the rules governing action, is deontology. The word deontology comes from the ancient Greek word, deontos , which means duty. Because duties oblige us to obey rules that govern actions or conduct, they bind or constrain the will ahead of action. In judging whether an action is right or wrong, deontology ignores consideration of harmful or beneficial consequences and relies on these rules of duty to serve as the standard of judgment. People usually have rules of duty or obligation in mind when they speak of ethical standards or worry that standards are breaking down. Examples of these rules include religious commandments to honor parents , not lie, or not steal and rules of social interaction such as treating people fairly, doing them no harm, or respecting their rights. Rights often are said to stand in reciprocal relation to duties. Thus, the right to free speech presupposes a duty to respect the right of others to speak or the public health obligation to ensure conditions for maintaining health presupposes a right to health .

Deontology as a theory owes most to Im manuel Kant’s view of the “good will” and his closely linked account of autonomy . A person of morally good will does the right thing for its own sake, which means acting purely for the sake of duty. Duties are moral rules or laws that bind the will and limit the scope of action. For Kant, basing decision for one’s action solely on duty without regard to the potential good or bad consequences of the action is the only legitimate basis for moral action. Kant even goes so far as to say that “a free will and a will under moral laws are one and the same” (Gregor et al. 2012 ).

Kant conceives duty as the quintessential expression of autonomy , which may come as a surprise to those who equate autonomy with rational free choice or even just following one’s preferences without interference. However, the meaning of autonomy for Kant derives from its literal meaning in Greek, autos (self) and nomos (law) ; namely, self-legislating. Autonomy enacts from within the moral rules and principles that bind the will and guide action. However, not every self-originating impulse should be obeyed; only actions conceivable as universal laws morally bind the will. Morally laying down the law for oneself entails legislating for everyone, but universally legislating does not mean asserting one’s will over others. Nor does it mean that the ethical content of a moral law or duty is valid eternally and everywhere. Rather, it refers to the “categorical imperative” an unconditional requirement for an action to be moral. To qualify as a duty, a rule that commands action must apply to every rational person. Stealing, for example, could never qualify as a duty , because a situation where everyone steals from everyone else would undercut the one-sided advantage of stealing that the thief hopes to exploit. Although self-directed, autonomous action is necessarily other-regarding.

Kant maintains that the categorical imperative can be expressed in two other ways equivalent to universality, namely, “respect for humanity” and a “kingdom of ends” (Gregor et al. 2012 ). In each, this other-regarding dimension of autonomy is evident. Respecting humanity means never treating persons as mere means or objects but always treating them as ends, that is, regarding them as fellow autonomous agents. Autonomously agreeing on actions, interventions, or policies requires that decision makers mutually consider and understand their reasons for action and be willing to abide by the rules derived from these reasons as laws they collectively impose upon themselves (O’Neill 2002 ).

The idea of a fellowship of mutual consideration comes out most clearly in Kant’s concept of a kingdom of ends. This concept is really the ideal of a systematic union or commonwealth of autonomous individuals making law s that apply to everyone. This ideal presupposes that ethical deliberation places respect for others as ends, as autonomous agents, above self-interest. The core idea is that we only consider actions that could gain acceptance by a community in which all see themselves as sovereigns who lay down universal laws binding on themselves and others. The hope is that the body of law governing society progressively embodies this ideal. Such mutual regard in laying down the moral laws that will bind one’s actions differs significantly from insistence on noninterference with individual free choice, let alone with personal preferences. Conversely, the aspiration behind Kant’s view of autonomy harmonizes well with the public health obligation to address collective problems through collective action.

For utilitarianism , judging the rightness of an action depends on an estimation of its subsequent practical outcome or result rather than on its conformity to principles of duty . Utilitarianism considers ethically best that course of action that will result in the greatest net benefits over harms. A utilitarian approach underlies cost-benefit analyses that weigh an intervention’s costs (risks , harms, burdens, or disadvantages) against its benefits (advantages, utility, improvements, cost savings). In addition to its focus on consequences, utilitarianism is egalitarian, communitarian, and scientific in outlook. It is egalitarian in considering everyone’s benefit and equally weighting each person’s good, as opposed to privileging certain people. It is communitarian in attempting to increase benefits to society rather than individuals, seeking the “greatest good for the greatest number.” It endeavors to be scientific by quantifying harms and benefits, accounting for probability, and calculating net benefit. Calculating net benefits over harms is less problematic when relevant factors employ a common scale of measurement, for example, weighing the financial costs of treating a disease with the cost savings from preventing that disease. Comparing different outcomes (e.g., financial costs versus quality-adjusted life years ) sometimes involves difficult judgments about the relative value of each outcome. Because the utilitarian approach seeks to determine and promote the collective good based on aggregate measures, it readily lends itself to justifying public health interventions .

3.5 Law Versus Ethics

Laws share certain deontological features with ethical principles of action (and with religious commandments). They all define one’s obligations or duties and typically take the form of rules or commands regarding what one should or should not do. They can lay down positive requirements to fulfill but more commonly establish parameters that prohibit certain actions or constrain liberty in some way. Laws do not differ from ethical rules primarily based on content, because an ethical rule can become a law without changing the rule’s content. For Kant, at least, the crucial difference between ethics and law concerns one’s reason for obeying; namely, whether one acts purely voluntarily out of a sense of duty or merely in external conformity with duty, either to appear to be moral or out of fear of penalty or punishment. Laws are rules enforced by penalty or punishment, which many people might otherwise break. Society can tolerate the flouting of some rules, but disobedience of more important rules can disrupt society or create danger. For these reasons, society establishes and enforces laws regarding socially important matters, not leaving their compliance up to individual prerogative. An ethical rule’s enactment as law, therefore, implies agreement by society or the law’s enactors on the importance of strictly regulating the behavior the law governs. Law can be a blunt instrument that effectively compels compliance, which suffices to satisfy the reasons for its enactment, even if it cannot coax voluntary obedience from an inward sense of duty.

In theory, deontologically evaluating a past or proposed action is a straightforward binary determination of compliance or noncompliance with a legal or ethical rule. In practice, however, defining a rule’s scope or determining exactly which actions fall under it can prove difficult. Moreover, when different rules apply, determining which should take precedence often becomes problematic, especially when they conflict . Lying to protect a relative, for example, can put the duty to speak truthfully into conflict with familial obligations . Determining which rule takes precedence can involve reasoning clearly from ethical principles , weighing the underlying values embodied in the law , or considering the practical impact of the intervention in context. Because laws demand compliance , they are more rigid. Additional legal stipulations can prioritize or specify how to apply laws in certain situations, but doing so increases their complexity. Ethical guidelines operate more flexibly than rigid, compulsory laws and more readily accommodate compromise. With ethical guidelines, decision makers can consider and rank the underlying values the ethical rules serve to promote. Doing so allows for trade-offs between competing ethical considerations and for deciding which values it makes sense to prioritize in the given context. Conversely, law’s comparative rigidity can be a virtue where only stricter oversight and enforcement will ensure compliance and establish order.

Across cultures, legal, ethical, and religious rules prohibiting basic offenses such as lying, theft and murder show considerable overlap. However, cultures vary in exactly which rules are matters of individual choice and which are matters of legal enforcement and punishment. This variability also applies to the status of rules and standards governing research on human subjects. Even within a country, significant variability can prevail in whether human subjects’ research rules and standards are legal regulations or ethical guidelines (U.S. Department of Health and Human Services 2015 ). Some se e the lack of legal regulation as a breach in protections, but others prefer guidelines, arguing that regulations tie reviewer hands, making it more difficult to make trade-offs or nuanced judgments based on moral discernment of the particulars of each case (Verweij and Dawson 2009 ). Because each approach offers advantages and disadvantages, political culture and local context must ultimately decide whether human subjects’ research rules exist as enforceable regulations or ethical guidelines .

Regardless of whether it takes the form of guidelines or law , research ethics will govern only a fraction of the ethical issues that the field of public health must address. In many areas of public health practice, there are no specific ethical guidelines or regulations . To address ethical challenges in these areas or to address emergent challenges, the ethical practice of public health therefore requires the ability to use general ethical frameworks. Such frameworks can employ checklists of questions and stepwise procedures. However, because novel challenges continually emerge and changing contexts introduce nuances no set of rules can anticipate, public health professionals ultimately need to practice ethical decision making over time in order to cultivate moral judgment and discernment.

By laying down and enforcing what may, must, or cannot be done, legal rules function as boundaries of acceptable behavior. Ethics, science, budgets or politics, each in its own way, also can restrict the scope of action. Public health practitioners and officials therefore first need to conduct a feasibility analysis to determine the relevant limits on possible interventions or policies. Determining these limits seldom will restrict the scope of action to a single possible course. Given multiple possibilities, most people will aspire to the best course of action beyond the legal floor of minimally acceptable behavior yet within the other relevant limits. As a result, the ethical challenges public health practitioners face seldom involve stark choices between right or wrong, good or evil. A good feasibility analysis will have ruled out any unethical or illegal options or alternative courses of action in advance. Rather, the tough choices more frequently involve selecting the best alternative from among competing goods, each of which to a greater or lesser degree realizes the public health goal and embodies relevant stakeholder values.

Whereas determining and complying with the various limits on action is largely an analytic process, designing alternatives is a synthetic, creative process. Alternatives should all realize the public health goal and incorporate the perspectives and values of subject matter experts and relevant stakeholders. Deciding upon the best alternative must take into account how it will realize the public health goal in a particular context and with respect to the stakeholders. For example, advocating contraceptives to reduce unwanted teen pregnancy might seem to promise success based on efficacy studies, but ethical controversy could render such a program less than optimal in some contexts. Political culture or social norms can confer partisan advantage or disadvantage to some alternatives, while other alternatives may enjoy an advantage because of the experience and expertise of a health department. Whatever alternative practitioners finally choose, their choice will presuppose a prioritizing of values. The foregoing account highlights why public health practitioners need to see ethics as something more than a compliance matter. It transcends compliance because public health ethics also involves practical decision making, which should include stakeholder analysis, the incorporation of stakeholder values in the design of alternatives, and a fair, transparent deliberative process to evaluate alternatives.

4 Public Health Ethics

Compared with more established fields of practical ethics such as clinical ethics , research ethics , and bioethics , the field of public health ethics is relatively new. Consequently, many public health practitioners may be better acquainted with these more established fields than with public health ethics. In particular, practitioners may already be acquainted with the four principles these fields rely on for ethical evaluation: beneficence , nonmaleficence , respect for persons (autonomy ), and justice (U.S. Department of Health, Education, and Welfare 1979 ; Beauchamp and Childress 2012 ). Being applicable to health and research , these four principles also are relevant to public health, but having arisen to address issues in other fields, they need to be adapted to a public health context. Even then, they still fall short in addressing the ethical challenges that arise in public health. Examining these related ethics fields and showing how the four principles fit into a public health context can serve by way of contrast to indicate what is distinctive about public health ethics.

4.1 Research Ethics , Clinical Ethics, and Bioethics : Principlism and the Four Principles

Research ethics entails the wider notion of scientific integrity but is best known and most developed in relation to medical research involving human subjects. The development of human subjects’ research ethics guidelines can neither be divorced from breaches of ethical conduct in human subjects’ research nor wholly reduced to a reaction to these events. But beginning with the Nuremberg Code ( 1947 ), balancing risks and benefits to research subjects and getting their informed consent have been cornerstones of international research ethics guidelines. Far more influential than the Nuremberg Code , the Declaration of Helsinki from the World Medical Association (WMA) is a fundamental document in international human subjects’ research ethics guidelines . Its initial 1964 version included provisions for proxy consent for those with diminished autonomy . Its 1975 revision called for review of research by an independent committee, now known as an ethics review committee (WMA 1964 , 1975, 2013). The use of such committees began spreading under the aegis of WHO and then in response to the HIV/AIDS pandemic, as the number of large-scale vaccine and drug trials grew in developing countries. In the United States , research regulations set forth in the Common Rule govern ethics review committees as well as all human subjects’ research that receives U.S. government funding (U.S. Department of Health and Human Services 2009 ). In the United States, a standing ethics review committee generally functions within a specific governmental or university institution and therefore is referred to as an institutional review board (IRB). Beginning in 1982, the Council for International Organizations of Medical Sciences (CIOMS) , in collaboration with WHO, proposed i nternational ethical guidelines for biomedical research involving human subjects (CIOMS 2002 ).

Our discussion of these documents has only highlighted key provisions of what is required to ensure the safety of human subjects. CIOMS’s most recent research guidelines ( 2002 ), for example, contain more than 60 pages of text, explanation, and commentary. But ensuring ethical conduct and scientific integrity in research requires more than the oversight function of ethical review committees. It also requires extensive training not only in research ethics but also in a number of related areas. Training and guidelines should cover, among other things, mentoring of junior researchers, authorship and publications policy , conflicts of interest that arise in partnerships and collaborative science, and data acquisition, management, sharing and ownership. Ethics training can help develop moral judgment. The hope is that training and application will enable practitioners to reason about new, difficult, or ambiguous cases in morally discerning ways.

Clinical ethics address the ethical issues that arise in clinical practice. Until the advent of bioethics , medical professionalism emphasized the health care provider’s obligation to prioritize the patient’s welfare, the health care provider’s professional judgment about what would most benefit the patient, and the importance of establishing patient trust . The traditional model of clinical ethics was frankly paternalistic . Under the influence of bioethics, many health care providers began embracing a more patient-centered model of care that emphasized patient autonomy and informed consent . This patient-centered model conceives care as a contract between patient and provider. The emphasis on contracts strikes some as an inappropriate consumerist model that undervalues professional judgment and undermines patient trust in the medical profession. Tensions between these two models have led to a compromise that reasserts the importance of medical professionalism and clinical judgment, while acknowledging the importance of respecting patient autonomy (ABIM Foundation et al. 2002 ).

Bioethics has a range of meanings, the first of which applies to ethical issues brought about by advances in biomedicine and biotechnology . Ethical issues that arise from using life-sustaining technologies in end-of-life and beginning-of-life care epitomize this sense of bioethics. But bioethics also arose in response to medical paternalism and to the abuse of human subjects in medical research . Bioethics has championed informed consent , patient autonomy in doctor-patient relationships and the safety of human subjects in research. However, many bioethicists think the focus on clinical ethics and on personal autonomy unduly restricts bioethics’ purview. They advocate a more holistic, social justice approach in bioethics, which has been referred to as “population-based bioethics” or “integrative bioethics” (Sodeke 2012 ). It can be argued that this expansion of bioethics beyond clinical ethics into population issues moves bioethics into the arena of public health ethics (Callahan and Jennings 2002 ).

Principlism came into being in a 1979 document called the Belmont Report (U.S. Department of Health, Education, and Welfare 1979 ). The report was the work of the U.S. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research , which convened in 1974 partly in response to the exposé of the U.S. Public Health Service Tuskegee Syphilis Study. The Belmont Report became the basis for revising 45 CFR 46, the so-called Common Rule , part of the legally binding U.S. Code of Federal Regulations, governing the protection of human subjects (U.S. Department of Health and Human Services 2009 ). The Belmont Report clearly explained the underlying ethical principles that informed existing regulations and provided an ethical framework for thinking about subsequent regulations. Principlism has remained the predominant ethical framework in biomedical ethics (Beauchamp and Childress 2012 ). Its explanatory groundwork accounts for much of its success, but its relevance to medicine and research , the prestige that attaches to these fields, and its compatibility with liberal individualism also have played a role.

Beneficence (doing good) and nonmaleficence (doing no harm) date back to the Hippocratic Oath as medical principles. Collapsing them both into beneficence, as the Belmont Report does, underscores the practical consideration that biomedical decisions generally aim to optimize net benefit over harm, rather than to maximize only benefits or minimize only harms or risks . However, these principles are distinct, not mere opposites. Not doing harm has a certain priority (first, do no harm), because not benefitting someone seems a less serious offense than doing that person harm. That priority partly reflects the human tendency more readily to forgive overlooked benefits (errors of omission) than deliberate actions resulting in harm (errors of commission).

Justice has several meanings that include due process and fair deliberative procedure, properly assessing what people are owed or due, and equitable distribution of burdens and benefits. According to philosophic tradition, justice has always functioned dually, applying to individuals but more importantly serving as an overarching principle for adjudicating competing claims in relation to the group or to other members of society. The phrase, “social justice ,” then, is redundant but in political contexts marked by individualism serves as a reminder of justice’s social dimension. In fact, this phrase came into vogue in public health circles to counter the ideology of “market justice,” which views the equal access of individuals to the free market as a valid, reliable, and preferred means for sorting out issues of economic and social justice (Beauchamp 1976 ). The notion of health equity , which compares different groups, primarily refers to this social dimension of justice , although denial of access to health care, a contributing factor to health inequity , violates what the individual is owed.

Respect for persons emphasizes that individuals, as agents in charge of their own lives and bodies, have the right to make decisions and choices free from undue interference. Respect for persons forms the basis of informed consent , namely, the right of patients and human research subjects to be informed of, and to assent to, medical or research procedures they might undergo, especially procedures that pose potential harm or risk . Conducting research on human subjects or performing medical procedures on patients without their prior knowledge or consent in most cases violates their personal autonomy . However, health professionals have a special (i.e., paternal) obligation to look out for the welfare of people with diminished decisional capacity—such as those in a coma or the very young—and to protect them from harm.

These four principles were originally conceived as prima facie principles, that is, each expressed a self-evident though not absolutely binding obligation and none had an inherent priority over another. However, in many Western countries and in the United States in particular, respect for persons has dominated discussion in bioethics , clinical ethics, and research ethics where it often takes precedence as a moral consideration over the other principles. This ascendancy most likely reflects the high value that these countries place on liberty and freedom . At any rate, in public discourse generally and in public debate about public health interventions , respect for persons often amounts to an insistence on noninterference with individual free choice or with personal preferences. Although Kant’s other-regarding idea of moral autonomy , harmonizes well with collective decision making, the insistence on noninterference with personal choice often creates impediments to the implementation of public health interventions . In part for this reason, the social justice movement has had to challenge the emphasis on respect for persons in order to promote the public good and health equity .

4.2 Contrast between Clinical Ethics and Public Health Ethics

Table 1.2 contrasts the individual focus of clinical ethics with the community/population focus of public health ethics. Because public health and clinical practice can overlap, the items in the respective columns represent tendencies along a continuum rather than stark opposites. Where separate agencies carry out public health services and medical care, these contrasts may be more pronounced. The overlap between public health and clinical practice makes it even more important to highlight their differences to bring out distinctive features of public health ethics.

The table makes clear that the Belmont principles of beneficence (seeking benefits), nonmaleficence (avoiding harm), respect for persons , and justice remain important in public health, but must be extended to accommodate the broader scope of public health interventions . This broader scope entails many types of professionals , interventions and policies that display a political and social dimension, and a wider range of activities such as community engagement, intersectoral collaboration , collective decision making, and governmental administration. As a result, prevailing political philosophies and culture will necessarily shape the way public health functions. The crucial point is that differences of scale that produce a higher order of complexity also produce qualitative differences that introduce different patterns of causation. Among other things, this means that social factors do not merely represent aggregated individual factors and so cannot always be addressed in the same way as individual factors.

4.3 Individual Versus Relational Autonomy

For understanding what is qualitatively distinct about public health, the contrast between respect for individual persons and the relational autonomy of community members is key. Respect for persons upholds an individual’s right to make independent decisions free from undue pressure, but relational autonomy emphasizes that individual actions occur in the context of other people whom these actions will affect. The potential harmful impact of individual action on the welfare of others sets a limit to individual action. Relational autonomy draws attention, then, to the interdependence of people living in communities and to the solidarity that arises from the emotional bonds that shared lives create. Anthropology teaches that people always find themselves in a network of social relations, while evolutionary biology has shown how profoundly people are built from the physiological ground up as sociopolitical beings. Because it presupposes the social context of language and reasoning ability, individual autonomy also depends developmentally on relational autonomy. That is, people only become autonomous through relations and interactions with others. As African humanism (ubuntu philosophy) epitomizes it, umuntu ngumuntu ngabantu , “a person is a person through other persons” (Louw 2008 ). Familial and communal deliberate processes are foundational for the development of individual autonomy and provide an even deeper basis for collective decisions than the type of solidarity that comes to the fore in crises or in the face of common predicaments. Kant would reject any suggestion that developmental context, emotional bonds or feelings of solidarity underpin moral autonomy. Nevertheless, moral autonomy and relational autonomy both display an inner-directed, but other-oriented feature that readily aligns with collective decision making.

These points about the foundational character of social relatedness, solidarity , interdependence , and communal decision making do not readily align with certain features of social contract theory , on whose principles liberal democracy is based. Whereas virtually every other political tradition conceives the sociopolitical realm as a natural feature of human life, social contract theory posits humankind’s original state, the state of nature, as one of solitary individualism . In this view, society or at least civil society come into existence voluntarily through a contract that creates government through the consent of the governed (Riley 1982 ). Although never seriously advanced as a scientific account of society’s origins, social contract theory nevertheless has exerted a powerful influence as a political founding myth. As such, it has made personal liberty , free choice, and consent of the governed presumptive values of societies whose governing political philosophy rests on social contract theory. By “presumptive,” we mean that the value, norm , or claim is assumed to be valid or have priority, so that the onus is on the person who objects to the presumption to justify a different value, norm, or claim.

4.4 Personal Autonomy as a Presumptive Value of Liberal Democracy

Personal autonomy in a clinical and research context generally means respect for the patient’s right to receive an explanation of a medical procedure or research intervention, to be informed of any potential benefits or harms, and to freely choose whether to accept the procedure or participate in the research. More generally and in other contexts, personal autonomy has come to mean an insistence on liberty , free choice, and noninterference with personal preferences. Personal autonomy in this more general sense owes more to John Stuart Mill’s nineteenth-century views on liberty than to Kant’s eighteenth-century idea of autonomy (O’Neil 2002 ; Dawson 2011 ). An important aspect of Mill’s view of liberty is the “harm principle ,” which holds that “the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others” (Mill 1989 ). What people choose to do regarding themselves is no business of government . Interfering with this private sphere of self-determination constitutes governmental paternalism . This interference diminishes the sphere of liberty that affords individuals the chance to direct their own lives and develop their talents and character to the highest degree. A chief advantage of democratic society, one that benefits the entire society, is the creative social dynamism that emerges from the synergism between individuals who are developing their talents and abilities.

Arguably, the primary aim of the harm principle is to promote the kind of individual self-development that benefits society rather than to champion every exercise of free choice. At any rate, some have sought to distinguish this edifying version of personal autonomy from an all-encompassing version that demands undue deference to any and all personal choices and preferences merely because they are personal (O’Neill 2002 ; Dawson 2011 ; Powers et al. 2012 ). Presuming, or insisting on, the validity of personal autonomy makes more sense in the delimited context of medicine and biomedical research on human subjects where an individual’s body is the focus of activity. It makes less sense in the far wider sphere of public health activity where social interactions and the interdependence of people come into play. Absolutizing personal autonomy in the sphere of public health would give effective veto power over every collective decision aimed at the public good to any individual who felt constrained by that decision. A more moderate version might distinguish levels of importance of personal choices and exercises of liberty . A collective decision concerning the public good could override some personal choices and limit liberty, even when they did not involve direct harm to others. Such decisions, when made in the context of a fair, transparent process of ethical deliberation involving stakeholders , are more likely to get buy-in from a community and less likely to be labeled paternalistic .

Because public health considers the relation between individuals and the collective good, it necessarily has a political dimension. How a country’s political culture balances this relation will drive and constrain public health practice and so shape the nature of the ethical frameworks that are appropriate to a country’s politics (Hyder et al. 2008 ). In the brief history of public health ethics, the most important ethics frameworks have emerged in the political context of liberal democracy. Many of these frameworks reflect the tensions between public health’s obligation to act collectively for the common good and the presumptive value of personal autonomy . The principle of least infringement and Kass’s code of restraint illustrate the effort to mediate such tensions (Kass 2001 ). The code of restraint strives to balance autonomy claims against the obligation to safeguard community health by determining what intervention most effectively protects health while minimally infringing on liberty . In a liberal political context that recognizes Mill’s harm principle , this strategy justifies the trumping of personal autonomy as long as imminent harm threatens the populace, for example, in a deadly outbreak of contagious disease. But where the threat of harm to others is indirect or not immediate, as with the obesity epidemic, the harm principle less readily justifies a liberty-limiting intervention such as banning or taxing certain foods. Utilitarian approaches that weigh the health advantages of intervention and the disadvantages of obesity clearly support obesity intervention, but limiting interventions to those that do not restrict personal choices also have limited effectiveness . In Chap. 6 , Jennings considers the relative merits of these approaches in his overview of the ethical issues in environmental and occupational public health. His discussion raises the question of the extent to which an ethical framework should adapt itself to the presumptive values of the political context or should reflect the nature of the practical field under investigation. To some extent, it must do both.

The three-step framework offered in the next section is designed to guide decision makers, through questions, to assess the ethical dimensions of a case, including which moral considerations (e.g., population utility or liberty ) may have more weight than others, given the issue or context. This contextual approach provides the flexibility and starting point for deliberation to accommodate the issues globally and to uncover the varying perspectives of stakeholders with potentially different presumptive moral norms (e.g., solidarity versus individual rights ).

5 Ethical Frameworks

What at first glance demarcates public health ethics from related fields of health ethics are the ethical problems that public health professionals typically encounter in their practice and the ethical frameworks used in practice to address these problems. Regarding these ethical problems, this casebook offers a representative, but not exhaustive, sample. Regarding ethical frameworks, this chapter has suggested two competing criteria for choosing. On the one hand, ethical frameworks should be grounded in their topics. Dawson ( 2011 ) expresses the point succinctly by arguing that public health should be the foundation of public health ethics. Accordingly, we have presented a view of public health ethics that builds on the definitions of public, health, and public health, and on the goals of public health practice. But we have also defined ethics and indicated how public health ethics draws on numerous ethical theories and can provide a moral guide grounded in the norms of benefiting others, preventing harms, and providing utility. We have pointed out its distinguishing principles based on the facts of community and interdependence . Lastly, we have situated public health ethics within the process of ethical decision making about which options are the most justifiable means to achieve public health goals in a particular context. In the end, grounding public health ethics in public health may require public health leaders to have the courage to advocate public health values and goals, even when that position is unpopular. Such a stance may be justified, for example, where the feasibility of a much-needed public health intervention requires a long-range strategy to change social norms or build social consensus .

On the other hand, precisely because public health itself is practical, pragmatic, and community oriented, an ethical framework designed for it must accommodate itself to a country’s presumptive values and political culture. This consideration illustrates that the feasibility of public health interventions usually depends on their alignment with the political culture, while their success usually implies public acceptance. Many established frameworks, like that of Kass, seem designed with a liberal political context in mind that gives presumptive weight to individual liberty , which may limit the range of interventions that can be justified. Newer approaches to ethical analysis in public health place more emphasis on social values like equity and solidarity , although these newer approaches often are difficult to put into practice (Lee 2012 ). In addition, while newer approaches may offer clear reasons to justify a broader range of interventions, the reasons may be less persuasive if they do not consider the presumptive values in context. For example, in Chap. 3 , Daniels discusses the ethical conflicts that arise during pandemics between the standard goal of improving population health and emergency contexts that demand allocating scarce resources in a way that treats people fairly. He asks, if in the pandemic context we believe that saving the most lives trumps giving priority to those who are sickest, can we justify revising the usual priority given to the sickest in health care?

Arguably, what would be most useful is not a set of frameworks designed for specific presumptive values , but, rather, a framework that can accommodate any presumptive values and consider them in relation to values rooted in public health or in context. The three-step framework that follows is a straightforward tool to help practitioners analyze the ethical tensions in a particular context. It addresses Daniels’ tough question directly by considering health care’s presumptive prioritization of the sickest in relation to the public health value of saving the most lives in a pandemic .

6 A Three-Step Approach to Public Health Decision Making

We offer the following framework, drawn from public health practice and described by Bernheim et al. ( 2007 ), as an example of an analytic tool that can guide decision makers through reasoning and deliberation. It is not meant to introduce a rigid application of ethical principles, nor does it presume that any one moral norm has greater weight that trumps other norms. Instead, the questions are designed to help decision makers clarify whether a particular moral norm (e.g., solidarity or liberty or equity ) is weightier than others in context, and if so, then strong reasons must be offered to override the presumptive moral norm . For example, during an epidemic, equity may carry presumptive weight and trump other moral norms in some contexts. Ethicists at the Joint Centre for Bioethics offered the following insight from the SARS experience:

In the case of an epidemic, it is important to control the spread of the disease, but as much attention should be paid to the rights of the noninfected patients who need urgent medical care. There may be as many people who died from other illnesses and could not get into hospital as there were who died from SARS. Equity is required in the amount of attention given to a wide array of people, including patients with and without SARS. Accountability for making reasonable decisions, transparency and fairness are expected …. (Singer et al. 2003 )

The questions clarify the relevant factors, such as stakeholder claims, alternative actions, and possible justifications for deciding on one course of action.

6.1 An Approach to Ethical Analysis and Justification in Context

Step I: Analyze the Ethical Dimensions of the Public Health Issue and Context

What are the risks , harms, or concerns?

What are the appropriate public health goals in this context?

What is the scope and legitimacy of legal authority, and which laws and regulations apply?

What are the moral norms and claims of stakeholders , and how strong are they?

Are precedent legal or ethical cases relevant for identifying the presumptive moral norms ?

Which features of the social-cultural-historical context apply?

Do professional codes of ethics provide guidance?

Step II: Formulate Alternative Courses of Action and Evaluate their Ethical Dimensions

What are the short- and long-term options, given the assessment of the public health issue and context in Step I?

What are the ethical dimensions and tensions of each option?

Utility: Does the public health action produce the best balance of benefits over harms and other costs ?

Equity and Justice : Is health equity advanced? Are the benefits and burdens distributed fairly (distributive justice )? Is there appropriate public participation , including the participation of affected parties (procedural justice )?

Respect for Individual and Community Interests: Does the public health action respect self-determination and human rights , as well as civic roles and community values (e.g., trustworthiness, solidarity ) (Dawson and Jennings 2012 )?

Other Moral Considerations in Public Health: Are there other moral considerations in public health that are important to consider? (For example, reciprocity, solidarity, protecting privacy and confidentiality; keeping promises and commitments; or disclosing information and speaking honestly, sometimes grouped as transparency.)

Step III: Provide Justification for a Particular Public Health Decision

Effectiveness : Is the public health action likely to be effective?

Proportionality : Will the probable benefits of the action outweigh the infringed moral considerations?

Necessity: Is the action necessary (i.e., will overriding a conflicting ethical norm achieve an important public health goal)?

Least Infringement : Is the public health action the least restrictive means available?

Public Justification: Can decision makers offer public justification in the political and cultural context that stakeholders , the public, and those most affected find acceptable?

Consider the following scenario described by Melnick ( 2015a ). A family adopted several children from a developing country with a high tuberculosis (TB) prevalence, including multidrug-resistant TB (MDR-TB) . Screening on arrival revealed that the children were infected with TB but did not have active disease and were not contagious. The family has strong religious beliefs about medical care and refused treatment , immunizations, and other preventive care. The children were home-schooled, but they did attend community activities. Soon after arrival one of the teenage children developed TB symptoms, and after several months the family consulted a pediatrician who diagnosed active pulmonary TB. Cultures revealed that the child had MDR-TB. Directly observed treatment (DOT) is part of the standard of care for active TB in the United States , and the local health department nurse visited the family to provide DOT. The parents objected to the home visit, stating that DOT was an invasion of their privacy and parental rights. The health department has the statutory authority to require in-person DOT and even impose isolation of the case and removal from the family to protect the public’s health. What should health officials do? Drawing on questions in Step I, health officials might first clarify the harms and risks and the goals of public health action. The public health goals are to prevent TB transmission and ensure the child receives appropriate care. Requiring DOT creates risks for the child such as side effects from treatment and social and behavioral harms associated with isolation and loss of privacy during visits, and potential community harm, by driving cases underground. Who are the stakeholders , and what are their moral claims?

There are several stakeholders: the child, the child’s family (including parents but also several siblings), and the public, which expects the health department to protect the community from TB. Regarding moral claims, the child has some expectations of freedom of movement, and privacy ; the family has similar expectations regarding privacy, respect for parental rights, and the freedom to administer medications to their child at a convenient time and place. However, these claims are not absolute, and competing moral claims can outweigh them. The child has a moral claim that could compete with her parent’s claim, specifically, that receiving DOT will reduce the risk of inappropriate treatment and relapse compared to having her parents administer the medications. In addition, the public has a moral claim based on two expectations: ( 1 ) that the health department will protect the community from TB, and ( 2 ) that people contagious for TB and other infectious diseases will protect others by behaving in an appropriate manner, including staying home when contagious and cooperating with treatment recommendations. This is especially concerning in this case because the immigration health officials had discussed the risks with the parents, warning them to seek treatment as soon as the child developed symptoms, yet the parents waited several months before taking the child to a pediatrician (Melnick 2015a , 175).

Consider another short scenario that illustrates the value of exploring options under Step II. A new policy is being considered that would require parental consent for newborn screening . Parental consent currently is not required, although newborn testing is not conducted if there are parental objections. The health department has been asked to take a position on the pending policy. What position should the health department take? What are the options?

Options include mandatory screening without consent , routine screening with advance notification (Opt In), routine screening without advance notification (Opt Out) (i.e., screening and testing done unless the parents object), voluntary screening (i.e., screening requires full consent and might also include a pre- and post-counseling session with each new mother). Some arguments that might be offered against requiring parental consent focus on the fact that (1) the benefits of screening are obvious and substantial, relative to potential harms; (2) parents have few good reasons to justify parental refusal and place their child at risk for harm; (3) obtaining consent from each parent is difficult, costly, and an unwarranted expenditure of time and money; and (4) the history of newborn screening has become acceptable and routine. Some arguments that may be raised for requiring parental consent include (1) parental consent is necessary because refusal of newborn screening is reasonable given the increasing list of diseases included in the battery of newborn tests and the low probability of many of these diseases; (2) newborn screening can have adverse consequences such as psychological harms associated with false positive tests; (3) long-term parental caretaking is enhanced when parents are included in all clinical decisions about their children ; and (4) the process of obtaining consent need not be time-consuming or burdensome but rather can help enhance the health professional-patient relationship (CDC 2012 ). Which arguments are stronger, and which of the options are the most ethically justifiable? The answer may depend on the social and political context in which the issue is considered, and which ethical values carry weight in that context. Whether there were presumptive values in place would be explored through the questions in Step I, which examines previous cases, the applicable laws and policies, and stakeholder claims in context. So, for example, in a society that has a strong moral norm or presumption for solidarity , there could be a presumption for continuing population newborn screening without parental consent . On the other hand, for a society that has a liberal political context that has a presumption for individual liberty , there may be a presumption for an option that seeks more explicit consent from parents . In either context, the presumptive moral norms are not determinative but are rebuttable, so the arguments or reasons to override those norms must be stronger.

Consider a third case from public health practice in which a person (the index case) infected with primary syphilis and HIV refuses to provide contact information for his wife, insisting that he and his wife had not had sexual relations for several years. Contact tracing and partner notification have been important tools historically for public health officials, although these interventions can involve thorny ethical tensions, requiring health officials to justify their decisions. In this type of situation, health officers will consider several options, starting with those that infringe least on the index case’s choices. For example, they might first provide to the index case additional information and assurance about confidentiality while allowing him to notify his wife voluntarily, either alone or with the help of public health workers. If this proves unsuccessful, other interventions might be considered, such as incentives, the threat of restrictions such as isolation, or attempts to notify the wife without his knowledge or consent . Each of these options would be determined in context, using the questions in Step III. Questions considered may include (1) Would the options likely accomplish the goal of warning and testing the wife without risking greater harm or possible adverse outcomes for the wife (e.g., domestic violence, loss of income, or loss of housing)? (2) Is there significant concern about a risk of harm to others, such as family members or children , so that the burdens and benefits of the action would not be distributed fairly? (3) Is the action the least restrictive of the important moral claims of the stakeholders ? (4) Is it necessary now to override conflicting claims to achieve the public health goal? Answering the questions in Step III helps decision makers consider whether actions are justifiable. As one health officer explains, “Public health officials should justify their decisions with deliberations that build not only community support and trust , but also build support and trust from the individuals and families directly affected” (Melnick 2015b ).

As the scenarios illustrate, public health is a social and political undertaking. Thus, making difficult choices in public health implicates important social, cultural, and political norms embedded in a particular context and community of stakeholders (Childress and Bernheim 2008 ). Regardless of whether decision makers work in a government public health agency, community nonprofit, nongovernmental organization (NGO) from another country, or a global organization, decision makers must rigorously assess the public health issue in context , to minimally be able to act “in ways that preserve the moral foundations of social collaboration” at the core of collective health activity (Calabresi and Bobbitt 1978 ).

The context specifically includes attention to stakeholders and relationships among public health stakeholders and community members, including the common understanding of their roles, obligations , and collaborations . Especially in global public health , it is important to note that even the decision makers are stakeholders, in some sense, and often, when they are health professionals , they have their own social-cultural norms and their own professional codes that can provide guidance. Appeals to the codes of particular professions, however, do not provide a sufficient justification for a public health decision, since justifications should be grounded in a society’s widely shared ethical values and norms .

Engaging stakeholders and addressing claims, especially those of the people most affected by a public health issue, in ethical analysis, is especially important and can sometimes support and strengthen the collaboration and cohesion needed for public acceptance of a decision. The ways to engage and reason with stakeholders in an ethical analysis will vary in different settings and communities, depending on community values , cohesion, and expectations, and can range from establishing an ethics board for deliberation, to gathering information from focus groups or social media, to including stakeholder representatives on the decision-making team. Stakeholder norms and claims are a critical feature for an ethical analysis in order to achieve a primary goal in public health—the development and maintenance of relationships of trust , defined in a report from IOM as “the belief that those with whom one interacts will take one’s interests into account, even in situations in which one is not in a position to recognize, evaluate, or thwart a potentially negative course of action by those trusted” (IOM 1996 ).

Ethical analysis is a dynamic process and, particularly for the practice of public health, is best accomplished through group deliberations that involve understanding others’ perspectives and thinking independently and imaginatively. Public health professionals often have to decide how best to realize numerous important societal norms and values when pursuing public health goals. Ethical tensions do occur in public health and at times require overriding an important principle , value, or moral consideration to undertake a justifiable public health action. However, a structured ethical analysis can often lead to imaginative alternatives that transcend or minimize ethical tensions and to decisions that most or many stakeholders find acceptable.

ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine. 2002. Medical professionalism in the new millennium: A physician charter. Annals of Internal Medicine 136: 243–246.

Article Google Scholar

Bartlett, R., and S. Collins. 2011. Aristotle’s Nicomachean ethics . Chicago/London: University of Chicago Press.

Google Scholar

Beauchamp, D.E. 1976. Public health as social justice. Inquiry 13(1): 3–14.

CAS PubMed Google Scholar

Beauchamp, T.L., and J.F. Childress. 2012. Principles of biomedical ethics , 7th ed. New York: Oxford University Press.

Bernheim, R.G., P. Nieburg, and R.J. Bonnie. 2007. Ethics and the practice of public health. In Law in public health practice , 2nd ed, ed. R.A. Goodman, 110–135. New York: Oxford University Press.

Chapter Google Scholar

Blane, D. 1999. The life course, the social gradient, and health. Social Determinants of Health 2: 54–77.

Blas, E., L. Gilson, M.P. Kelly, et al. 2008. Addressing social determinants of health inequities: What can the state and civil society do? Lancet 372(9650): 1684–1689.

Article PubMed Google Scholar

Braveman, P. 2006. Health disparities and health equity: Concepts and measurement. Annual Review of Public Health 27: 167–194.

Brunk, C.E., L. Haworth, and B. Lee. 1991. Value assumption in risk assessment: A case study of the alachlor controversy . Waterloo: Wilfrid Laurier University Press.

Calabresi, G., and P. Bobbitt. 1978. Tragic choices . New York: Norton.

Callahan, D., and B. Jennings. 2002. Ethics and public health: Forging a strong relationship. American Journal of Public Health 92(2): 169–176.

Article PubMed PubMed Central Google Scholar

Centers for Disease Control and Prevention (CDC). 2011. Advancing excellence & integrity of CDC science. Public health ethics . http://www.cdc.gov/od/science/integrity/phethics/ . Accessed 14 Feb 2014.

Centers for Disease Control and Prevention. 2012. Unit 2: Ethics and the law. In Public Health Law 101: A foundational case for public health practices. Public Health Law Program, Centers for Disease Control and Prevention. http://www.cdc.gov/phlp/publications/phl_101.html . Accessed 24 June 2015.

Childress, J.F., and R.G. Bernheim. 2008. Public health ethics: Public justification and public trust. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 51(2): 158–163. doi: 10.1007/s00103-008-0444-6 .

Article CAS PubMed Google Scholar

Childress, J.R., R.R. Faden, R.D. Gaare, et al. 2002. Public health ethics: Mapping the terrain. Journal of Law, Medicine & Ethics 30(2): 170–178.

Council for International Organizations of Medical Sciences (CIOMS). 2002. International ethical guidelines for biomedical research involving human subjects . Geneva: Council for International Organizations of Medical Sciences. http://www.cioms.ch/publications/layout_guide2002.pdf . Accessed 14 Feb 2014.

Dawson, A. 2011. Resetting the parameters: Public health as the foundation for public health ethics. In Public health ethics: Key concepts and issues in policy and practice , ed. A. Dawson, 1–19. Cambridge: Cambridge University Press.

Dawson, A., and B. Jennings. 2012. The place of solidarity in public health ethics. Public Health Reviews 34: 65–79.

Dawson, A., and M. Verweij. 2007. The meaning of “public” in public health. In Ethics, prevention, and public health , ed. A. Dawson and M. Verweij, 13–29. Oxford: Clarendon Press.

Faden, R., and S., Shebaya. 2010. Public health ethics. In Stanford encyclopedia of philosophy , ed. E. N. Zalta. http://plato.stanford.edu/archives/sum2010/entries/publichealth-ethics/ . Accessed 14 Feb 2014.

Freiler, A., C. Muntaner, K. Shankardass, et al. 2013. Glossary for the implementation of Health in All Policies (HiAP). Journal of Epidemiology and Community Health 67: 1068–1072. doi: 10.1136/jech-2013-202731 .

Gregor, M., J. Timmermann, and C.M. Korsgaard (eds.). 2012. Kant: Groundwork of the metaphysics of morals . New York: Cambridge University Press.

Hyder, A., M. Merritt, J. Ali, N. Tran, K. Subramaniam, and T. Akhtar. 2008. Integrating ethics, health policy and health systems in low- and middle-income countries: Case studies from Malaysia and Pakistan. Bulletin of the World Health Organization 86(8): 606–610.

Institute of Medicine (IOM). 1988. The future of public health . Washington, DC: National Academy Press.

Institute of Medicine. 1996. Healthy communities: New partnerships for the future of public health . Washington, DC: National Academy Press.

Jennings, B. 2007. Public health and civic republicanism. In Ethics, prevention, and public health , ed. A. Dawson and M. Verweij, 30–58. Oxford: Oxford University Press.

Kass, N. 2001. An ethics framework for public health. American Journal of Public Health 91(11): 1776–1782.

Article CAS PubMed PubMed Central Google Scholar

Kickbusch, I. 2003. The contribution of the World Health Organization to a new public health and health promotion. American Journal of Public Health 93(3): 383–388.

Krimsky, S., and A. Plough. 1988. Environmental hazards: Communicating risks as a social process . Dover: Auburn House.

Lee, L.M. 2012. Public health ethics theory: Review and path to convergence. Journal of Law Medicine & Ethics 40(1): 85–98.

Louw, D.J. 2008. The African concept of ubuntu and restorative justice. In Handbook of restorative justice: A global perspective , ed. D. Sullivan and L. Tifft, 161–171. New York: Routledge.

Marks, L., D.J. Hunter, and R. Alderslade. 2011. Strengthening public health capacity and services in Europe: A concept paper . Geneva: World Health Organization. http://www.euro.who.int/__data/assets/pdf_file/0007/152683/e95877.pdf . Accessed 10 Dec 2013.

Marmot, M. 2007. Achieving health equity: From root causes to fair outcomes. Lancet 370: 1153–1163.

Melnick, A.L. 2015a. Chapter 8, Containing Communicable Diseases: Personal Control Measures. In Essentials of public health ethics, ed. R.G. Bernheim, J.F. Childress, R.J. Bonnie, and A.L. Melnick, Burlington: Jones & Bartlett Learning.

Melnick, A.L. 2015b. Chapter 6, Case finding: Screening, testing, and contact tracing. In Essentials of public health ethics, ed. R.G. Bernheim, J.F. Childress, R.J. Bonnie, and A.L. Melnick, Burlington: Jones & Bartlett Learning.

Michaels, D. 2008. Doubt is their product: How industry’s assault on science threatens your health . New York: Oxford University Press.

Mill, J.S. 1989. In On liberty and other writings , ed. S. Collini. Cambridge: Cambridge University Press.

Nuremberg Code . 1947. Trials of war criminals before the Nuremberg Military Tribunals under Control Council Law No. 10 , vol. 2, 181–182. Washington, DC: U.S. Government Printing Office, 1949. http://www.hhs.gov/ohrp/archive/nurcode.html . Accessed 3 June 2014.

O’Neill, O. 2002. Autonomy and trust in bioethics (Gifford lecture) . Cambridge: Cambridge University Press.

Book Google Scholar

Ortmann, L., and J. Iskander. 2013. The role of public health ethics in vaccine decision making: Insights from the Centers for Disease Control and Prevention. In Vaccinophobia and vaccine controversies of the 21st century , ed. A. Chatterjee, 291–305. New York: Springer.

Powers, M., and R. Faden. 2006. Social justice: The moral foundations of public health and health policy . New York: Oxford University Press.

Powers, M., R. Faden, and Y. Saghai. 2012. Liberty, mill and the framework of public health ethics. Public Health Ethics 5(1): 6–15.

Public Health Functions Steering Committee. 1994. Essential public health services . http://www.health.gov/phfunctions/public.htm . Accessed 2 Jan 2014.

Public Health Leadership Society. 2002. Principles of the ethical practice of public health . http://phls.org/CMSuploads/Principles-of-the-Ethical-Practice-of-PH-Version-2.2-68496.pdf . Accessed 1 Feb 2013.

Riley, P. 1982. Will and political legitimacy: A critical exposition of social contract theory in Hobbes, Lock, Rousseau, Kant, and Hegel . Cambridge, MA: Harvard University Press.

Ruger, J. 2010. Health and social justice . New York: Oxford University Press.

Sen, A. 2009. The idea of justice . London: Allen Lane.

Singer, P.A., S.R. Benatar, M. Bernstein, et al. 2003. Ethics and SARS: Lessons from Toronto. British Medical Journal 327(7427): 1342–1344.

Sodeke, S. 2012. Tuskegee University experience challenges conventional wisdom: Is integrative bioethics practice the new ethics for the public’s health? Journal of Health Care for the Poor and Underserved 23(4): 15–33. doi: 10.1353/hpu.2012.0169 .

U.S. Department of Health and Human Services. 2009. Code of Federal Regulations, Title 45, Part 46, Protection of Human Subjects. http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html . Accessed 3 June 2014.

U.S. Department of Health and Human Services. 2015. International Compilation of Human Research Standards. Office for Human Research Protections. http://www.hhs.gov/ohrp/international/intlcompilation/2015internationalcompilation.doc.doc . Accessed 23 June 2015.

U.S. Department of Health, Education, and Welfare. 1979. The Belmont report: Ethical principles and guidelines for the protection of human subjects of research , Publication No. (OS) 78-0012. Washington, DC: U.S. Government Printing Office.

Verweij, M., and A. Dawson. 2009. Public health ethics: A research agenda. Public Health Ethics 2(1): 1–6.

Whitehead, M. 1992. The concepts and principles of equity and health. International Journal of Health Services 22(3): 429–445.

Winslow, C.-E.A. 1920. The untilled fields of public health. Science 51(1306): 23–33.

World Health Organization (WHO). 2006. Constitution of the World Health Organization–Basic documents , 45th ed., suppl. www.who.int/governance/eb/who_constitution_en.pdf . Accessed 29 Apr 2014.

World Health Organization (WHO). 2007. A conceptual framework for action on the social determinants of health (Discussion paper draft) . Geneva: Commission on Social Determinants of Health, World Health Organization. http://www.who.int/social_determinants/resources/csdh_framework_action_05_07.pdf . Accessed 4 Mar 2014.

World Health Organization (WHO). 2008. Closing the gap in a generation: Health equity through action on the social determinants of health , Final Report of the Commission on Social Determinants of Health. Geneva: Commission on Social Determinants of Health, World Health Organization. http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf . Accessed 4 Mar 2014.

World Medical Association (WMA). 1964, 1975, 2013. WMA Declaration of Helsinki—Ethical principles for medical research involving human subjects . http://www.wma.net/en/30publications/10policies/b3/ . Accessed 4 Mar 2014.

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Ortmann, L.W. et al. (2016). Public Health Ethics: Global Cases, Practice, and Context. In: H. Barrett, D., W. Ortmann, L., Dawson, A., Saenz, C., Reis, A., Bolan, G. (eds) Public Health Ethics: Cases Spanning the Globe. Public Health Ethics Analysis, vol 3. Springer, Cham. https://doi.org/10.1007/978-3-319-23847-0_1

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Ethical Issues in Public Health *

The field of public health includes a wide scope of activities and professional disciplines, ranging from sanitation, health protection, epidemiology, environmental health, financing, health promotion, including supervision, or the provision of clinical care. Each of these disciplines works in systems that face ethical dilemmas, making it important that public health workers have motivation to understand and practice within the ethical guidelines of their profession, thus making ethics an important component of training and practice. The dangers of ethical lapses are overwhelmingly apparent in the case of the Eugenics movement of the early 20 th century which metamorphosed from forced sterilizations in many liberal democratic countries into mass murder of physically and mentally handicapped children and adults in Nazi Germany. Between 1939 and 1941, 180 thousand psychiatric patients along with an equivalent number of handicapped children and adults were killed in an organized extermination program in Germany by lethal gassing. This method was then applied to the industrialized murder or Holocaust of six million Jews and millions of other “untermenschen” (sub human) in the greatest genocide in human history. Shortly after World War II ended the Nuremberg Trials of Nazi war criminals were conducted including medical doctors, and some were executed for crimes against humanity. This was followed by the 1948 United Nations Declaration on Human Rights and by the World Medical Association’s Helsinki Declaration. Both are widely accepted as cornerstone documents—the latter specifically governing ethical standards related to human experimentation—and are revised regularly since being issued in 1964. But genocide has not disappeared, nor has unscrupulous experimentation such as the Tuskegee experiment on black Americans infected with syphilis and left untreated even after the availability of a cure, penicillin. Ethical standards are now required by “Helsinki Committees”—ethical review boards—in most medical facilities worldwide. Ethical frameworks have evolved in part due to bitter experience of ethical failures later recognized and affecting public health standards of practice. Future generations of public health leaders and staff will face many ethical issues such as mandatory immunization of health workers and school children, and assisted death of terminally ill patients.

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Nuremberg Trial of Nazi war criminals, 1945–46. Available at: https://fcit.usf.edu/holocaust/resource/gallery/N1945.htm .

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Entrance to the infamous Auschwitz-Birkenau death camp where 6,000 people were put to death in gas chambers daily by the Nazi regime in World War II.

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Hungarian Jews arriving at Auschwitz near end of WWII for immediate gassing/extermination.

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Tuskegee Syphilis Study Participants. Courtesy: National Archives Catalogue, Tuskegee Syphilis Study Administrative Records, 1929–72 .

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Eleanor Roosevelt (1884–1962) former First Lady of the US, leading human rights diplomat reading the Universal Declaration of Human Rights, United Nations November 1949, United Nations, Lake Success, New York. Photo # 117539, United Nations Photo Library at http://www.unmultimedia.org/photo/ .

The Universal Declaration of Human Rights (UDHR) is a milestone document in the history of human rights. Proclaimed by the United Nations General Assembly in 1948 it provides a “Magna Carta” as a common standard for all peoples and all nations. Arising from the horrors of genocide and mass civilian casualties of World War II, the Declaration of Human Rights sets out, for the first time, fundamental human rights to be universally protected. It also provides a context for the complex topic of ethics in public health.

Ethics is a branch of philosophy that deals with the distinction between right and wrong—with the moral consequences of human actions. The ethical principles that arise in epidemiologic practice and research include:

• Informed consent
• Confidentiality
• Respect for human rights
• Scientific integrity

The Centers for Disease Control (CDC) in the US defines public health ethics: “ As a field of study, public health ethics seeks to understand and clarify principles and values which guide public health actions. Principles and values provide a framework for decision making and a means of justifying decisions. Because public health actions are often undertaken by governments and are directed at the population level, the principles and values which guide public health can differ from those which guide actions in biology and clinical medicine (bioethics and medical ethics) which are more patient or individual-centered .

As a field of practice, public health ethics is the application of relevant principles and values to public health decision-making. Public health ethics inquiry carries out three core functions ,

1. identifying and clarifying the ethical dilemma posed
2. analyzing it in terms of alternative courses of action and their consequences
3. resolving the dilemma by deciding which course of action best incorporates and balances the guiding principles and values (CDC) .”

Ethics in health is based on the fundamental values and concepts of a society. Medical ethics of the Hippocratic Oath hold the first obligation of a physician is to do no harm. The principle that saving a life is valued above all other religious considerations is of Biblical origins (i.e., Sanctity of Life or Pikuah Nefesh ), where the saving of a life is equivalent to saving the world. This implies that all measures available are to be used, irrespective of the condition of the patient or the cost. But if sickness and death are seen as acts of God, possibly as punishment for sin, then prevention and treatment may be considered to be interfering with the Divine will, and ethical obligation may be limited to relief of suffering. Humanism balances these two ethical imperatives: saving of life and relief of suffering. Materialism may see health care as primarily a function to preserve health for societal well-being and economic prosperity.

The role of society in protecting the health of the population evolved during the latter 19 th century with the sanitation movement and the gradual development of safe water supply, safe management of sewage and waste, and food safety with pasteurization, improving living conditions as well as medical care and the widespread implementation of national health insurance. Countries in Europe and the Americas began to recognize public health as societal obligations at municipal, state and national levels as part of fundamental values and concepts of a society. The astonishing success of public health over the past century increased life expectancy in high-income countries by some 30 years, mostly through improved sanitation, nutrition, living conditions and disease control measures, as well as societal and medical advances making care available to all. In the 1970s, the Lalonde concept emerged that individual behavior was one of the key health determinants, along with human biology, environment and medical care (see Chapter 21). This placed much of the responsibility for illness and its prevention on individual behavior, but at the same time fostered the development of health promotion as an essential component of public health theory and practice. All these points of view are involved in the ethical issues of the New Public Health (see Box 13.1 ).

Values and Ethical Principles of Public Health

1. Nonmalfeasance : Hippocratic Oath—do no harm.
2. Sanctity of human life : Biblical edict—saving a life comes before all other religious acts.
3. Universal Declaration of Human Rights : All humans deserve protection of life, health and well-being.
4. Individual human rights : Liberty, privacy, protection from harm.
5. Solidarity : Sharing the burden of promoting and maintaining health.
6. Beneficence : Reduce harm and burdens of disease and suffering.
7. Proportionality : Restriction on civil liberties must be legal, legitimate, necessary, and use the least restrictive means available.
8. Reciprocity : All have a right to just treatment but share responsibility to ensure justice especially for those facing heavy social and health burdens.
9. Transparency : Honest and truthfulness in the manner and context in which decisions are made must be clear and accountable.
10. Precautionary : Duty to take preventive action to avoid harm even before scientific certainty has been established.
11. Responsibility to Act : Public health officials and policy-makers have a duty to act and implement preventive health measures demonstrated to be effective, safe, and beneficial to population health. Failure to enforce public health regulations with resulting disease or deaths may constitute negligence on the part of responsible officials with civil or even criminal penalties.
12. Equity : Reduce gender, ethnic, social, economic, geographic inequities.
13. Cost and benefits : Economic analysis and consideration of priorities.
14. Stewardship : Responsibility of governance to act in a trustworthy and ethical manner.
15. Trust : Cooperation between the many public and non governmental stakeholders in health.
16. Evidence based : Decisions should be evidence-based, and revised, considering new evidence.
17. Responsive to needs : Address challenges as they may be anticipated and occur with close monitoring of health status.

Resources for health care are limited even in high-income countries, so that priority setting and judicious allocation of resources is always an issue. Money spent on new technology with only marginal medical advantages is often at the expense of well-tried and proven lower-cost techniques to prevent or treat disease. The potential benefits gained by the patient from more interventions are sometimes very limited in terms of length- or quality of life. These are difficult issues when the commitment to do all to preserve the life of the patient conflicts with the patient’s concept of quality of life and his or her right to decline, or terminate heroic measures of intervention. Terminally ill patients may endure suffering during radical treatment, which may prolong life by only hours or days, clashing with the physician’s ethical obligation to do no harm to the patient. The ethical value of sustaining the life of a suffering, terminally ill patient is a growing medical dilemma. The issue is even more complex when economic values are part of the equation. There is a potential conflict between the economic issues, the role of the physician in preserving life, the physician’s obligation to do no harm, the felt needs of the patient and his or her family, and the needs of the community. The right of patients to seek euthanasia or assisted suicide in end-of-life situations is increasingly recognized and practiced in some jurisdictions.

The state represents organized society and has, among its responsibilities, a duty to promote healthful conditions and to provide access to both medical care and public health services. The dissonance between individual rights and community needs is a continuous issue in public health. Application of accepted public health measures for the benefit of people in society may require applying an intervention to everyone in a community or a nation. A democratic society ruled by law and legal protection of human rights may justifiably need to place limits on individual liberties to achieve the goal of reducing disease or injury in the population. Raising taxes and other restrictions on alcohol and tobacco products, laws on mandatory speed limits, driving regulations including seat belt usage, car seats for children and mandatory immunization for school attendance are examples of public health restrictive interventions which place limits on individuals but protect those individuals, their neighbors and the community-at-large from harm.

Some forms of mass medication are accepted methods of public health practice to reduce the risk of disease in the population. Chlorination of community water supplies is a well-established, effective, and safe intervention to protect the public health. Fluoridation of drinking water to prevent tooth decay in children means that other persons are also drinking the same fluoridated water, which is of less direct benefit to them. Mandatory pasteurization of milk is an important standard for public health. Fortification of basic foods with vitamins and minerals is also a cost-effective community health measure and banning of trans fats to reduce heart disease, are all topics with advocates and opponents. The addition of folic acid to food as the most effective way to prevent neural tube defects (NTDs) in newborns is an intervention mandated by the US Food and Drug Administration (USFDA) and in over 80 other countries since 1998 (see Chapter 20). Use of mass immunization is essential for infectious disease control and mass medication is successful for control of “Neglected Tropical Diseases”.

Individual and Community Health

Confidentiality to assure the right of the individual to privacy involves ethical issues in the use of health information systems. Records of birth, death, reportable communicable and selected noncommunicable conditions (such as cancers, birth defects, neurological conditions), and hospitalization data—e.g. admissions by cause, length of stay—are essential data bases providing basic tools of epidemiology and health management. The use of detailed individual data, such as in mandatory reporting of infectious diseases and birth defects, e.g., is needed for case-finding and follow-up activities which is vital for population health monitoring and good epidemiologic management of disease outbreaks and routine monitoring functions of public health. However, caution is needed in data use to avoid individual identification to prejudice privacy, or that could be used punitively, such as in denial of access to health insurance or employment for smokers, alcoholics, or AIDS patients on the grounds that these are known causes of health damage that may be attributed to self-inflicted risk factors or preexisting conditions. This may become even more important if preexisting conditions or genetic susceptibility come to be used as determining factors to access health insurance or employment. Reporting is mandatory for physical for sexual abuse and criminally linked injuries as a measure essential for protection of vulnerable groups such as children, women, elderly, ethnic minority groups, or the general public from serious harm from bullying, abuse, violence or incitement to genocide.

Protection of the individual’s rights to privacy, and freedom from arbitrary and harmful medical procedures or experiments may clash with the rights of the community to protect itself against harmful health issues. This conflict comes into much of what is done in public health practice, which has both an enforcement basis in law and practice as well as a humanitarian and protective aspect based on education, persuasion, and incentives. Society permits, indeed requires its governments to act for the common good, but sets limits that are protected by the constitution, laws, courts and administrative appeal mechanisms.

Democratic societies have the right and obligation to legislate work, including mine and construction safety regulations, and traffic safety including speed permitted, wearing seat belts, use of car seats for small children and non-use of cellphones during driving. Offenders may be punished by significant fines and be subjected to strict educational efforts to persuade them to comply. Similarly, the community must ensure sanitary conditions to prevent hazards or nuisances for neighbors. Society must act to protect the environment against the unlawful poisoning of the atmosphere, water supply, or earth. Enforcement is a legitimate and necessary activity of the public health network to protect the community from harm. Table 13.1 shows topics where individual rights and responsibilities predominate, and a second set of rights that are the prerogative of the community to protect its citizens against public health hazards. Sometimes the issues overlap with political, advocacy, or legal action so that court decisions or new laws are needed to adjudicate precedents for the future.

Individual and Community Rights and Responsibility in Health: Ethical/Legal Issues

Ethical/Legal Issues	Individual Rights and Responsibilities	Community Rights and Responsibilities
Sanctity of human life	Individuals responsible to avoid behavior damaging their own health and that of others	Responsible for providing a feasible basket of service; equitable access for all
Individual vs. community rights	Immunization for individual protection	Immunization for herd immunity and community protection; education; community may mandate immunization
Right to health care	All are entitled to needed emergency, preventive, and curative care	Community right to care regardless of location, age, gender, ethnicity, medical condition, and economic status
Personal responsibility	Individual responsible for health behavior, diet, exercise, and nonsmoking	Community education for health-promoting lifestyles; avoid “blame the victim”
Corporate responsibility	Management accountability to criminal and civil action	Producer, purveyor of health hazard accountablity for individual and community damage
Provider responsibility	Professional, ethical care, and communication with patient	Ensure access to well-organized health care, accredited to accepted standards
Personal safety	Protection from individual, family, and community violence	Public safety, law enforcement, protection of women, children, vulnerable groups and elderly, safety from terrorism
Freedom of choice	Choice of health provider, limitations of gatekeeper functions, control costs function, right to second opinion, and right of appeal	Confidentiality, informed consent, birth control ensuring individual rights, limitations of self-referrals to specialist
Euthanasia	Individual’s right to assisted death within limitations by societal, ethical, and legal standards	Assure individual and community interests; prevention of abuse by family or others with conflict of interest
Confidentiality	Individual’s right to privacy, limitation of information	Mandatory reporting of specified diseases; data for epidemiological analysis
Informed consent	Right to know, risks vs. benefits; agree or disagree to treatment or participation in experiments	Helsinki Committee approval of research; regulate fair practice in right to know; Patient’s Bill of Rights
Birth control	Right to information and access to birth control and fertility treatment; woman’s rights over her body	Political, religious limited promotion of fertility; alternatives to abortion; legal protection of women’s right to choose
Access to health care	Universal access, prepayment; individual contribution through workplace or taxes	Solidarity principle and adequate funding; right to cost containment, limitations on service benefits
Regulation and incentives to promote preventive care	Social security for hospital delivery, attendance for prenatal care; primary care, ambulatory care; home care	Incentive grants to assist communities for programs of national interest; limit institutional facilities
Global health	Human rights and aspirations; economic development, health, education, and jobs	Reduction of health risks; occupational hazards and environmental damage
Rights of migrants and minorities	Equality in universal access	Pro-active outreach for high-needs groups
Prisoners’ health	Human rights	Security and human rights; reduce inequalities in sentencing convicts, harsh dangerous conditions in prisons; prohibition of torture and execution
Allocation of resource	Lobbying, advocacy for equity and innovation	Adequate resources for health; equitable distribution, targeting high-risk groups; cost containment

The 20 th century was replete with mass murders, executions, and genocide with nationalistic, ideological, and racist motives perpetrated by fascist, Stalinist, and radical xenophobic political movements when gaining governmental power by election or by revolution, in some cases using then-common public health terminology and concepts. In the 21 st century, radical jihadist terrorist groups and governments such as in Syria not only conduct mass killing of civilians, but also target ethnic minorities and religious groups with active genocide including deliberate use of chemical weapons, mass starvation, rape, murder and enslavement against civilians with bombings of civilians, medical workers, and hospital facilities.

Public health policy is guided by two distinct but interactive paradigms; the biotechnological disease and the social-ecological health paradigms. In the 19 th century these were the Germ Theory and the Miasma Theories, long at loggerheads, yet both produced enormous gains in public health. The biomedical paradigm addresses alleviation of disease risk or manifest diseases, with immunizations, screening and risk-factor reduction. The social health paradigm addresses the improvement of the physical and socioeconomic environment and healthy living, with the objectives of reducing disease and inequities in health between socioeconomic and regional population health disparities.

During the early part of the twentieth century, a segment of the social hygiene movement adopted ideas of racial improvement by compulsory termination of pregnancies and sterilization of the mentally ill, retarded, and other “undesirable persons.” By 1935, when the Nazi sterilization laws were passed, about 20 states in America already had sterilization laws in effect with concurrence of the US Supreme Court. American eugenics policies were praised by Hitler, and these ideas were adopted in Nazi Germany leading to execution of half a million “undesirables” under the eugenics concept, and were adapted for mass extermination of Jews, Gypsies, homosexuals, and others during the Holocaust.

The policies of eugenics were widely promoted by medical professionals in Sweden, the United States and Canada. This led to adoption of policies and programs to force legally sanctioned sterilization of mentally handicapped or mentally ill patients. This practice was attractive to Nazi policy before and after its rise to power in 1933, with wide support among the medical and psychiatric professions. Between 1939 and 1941, 180,000 psychiatric and physically handicapped patients were killed in Germany with the active participation by medical doctors, psychiatrists, nurses, and ancillary personnel under direct guidance of the so called T4 program, named after the address of Hitler’s headquarters from where it was directed.

This corruption of public health distorted a socially oriented concept of public health to a racially oriented policy with horrendous actions of mass murder in the name of racial purity as a public health policy. This policy was supported and implemented by leading psychiatrists in a number of western liberal democratic countries providing a precedent adopted and expanded in monstrous manners in Nazi Germany with nearly total support and participation of a highly Nazified medical profession. The T4 program utilized starvation and gassing to kill helpless people and these methods became the direct antecedent to the mass murder of Jews, Gypsies, homosexuals, Soviet prisoners, and other “undesirables.”

A noted Cambridge professor of modern history, Sir Richard Evans wrote:

“At the heart of German history in the war years lies the mass murder of millions of Jews in what the Nazis called “the final solution to the Jewish question in Europe”. This book provides a full narrative of the development and implementation of this policy of genocide, while also setting it in the broader context of Nazi racial policies toward the Slavs, and toward Gypsies, homosexuals, petty criminals and ‘asocials’.” (preface xiv). Evans continues: “For many years, and not merely since 1933, the medical profession, particularly in the field of psychiatry, had been convinced that it was legitimate to identify a minority of handicapped as ‘a life unworthy of life’, and that it was necessary to remove them from the chain of heredity if all the many measures to improve the health of the German race under the Third Reich were not to be frustrated. Virtually the entire medical profession has been actively involved in the sterilization programme, and from here it was but a short step in the minds of many to involuntary euthanasia” (page 82). “By the time the main killing programme had ended, in August 1941, a large part of the medical and caring professions had been brought in to operate the machinery of murder.… the circle of those involved had grown inexorably wider, until general practitioners, psychiatrists, social workers, asylum staff, orderlies, nurses and managers, drivers and many others had become involved, through a mixture of bureaucratic routine, peer pressure, propaganda and inducements and rewards.… Having proved itself in this context, it was ready to be applied in others, on a far larger scale.” (p. 101). The T4 euthanasia program was administered directly from Hitler’s main office “The euthenasia program was preceded by mass sterilization of nearly 400,000 ‘unfit’ Germans before the war broke out” (p. 105). (Evans RJ. The Third Reich at War. New York: Penguin Press, 2006).

The human and national cost of genocide lasts for generations. The hatred and fear may wane, but the trauma goes deep. It lasts with the victims and their descendants, but also with the perpetrating country and its culture. The Nazi Holocaust has downstream effects in public health in German-speaking countries over 65 years since the events took place. The eugenic theory assumption was that a healthy population must be “free” of “racially contaminated” individuals and inferior groups which led to a public policy to eliminate racially “unclean” members through forced sterilization and murder opening the door to a euthanasia program of mass execution of mentally and physically handicapped Germans and others in psychiatric facilities, which provided a working model for the industrialized murder of the Holocaust. This was in direct conflict to a 200-year tradition of Germany’s socially-oriented public health grounded in the political philosophy of human rights and social justice, many of whose advocates were mostly exiled or murdered. Many of the Nazi oriented academic medical leaders during World War II remained in key positions in the German public sector for many following decades.

The Nuremberg Doctors Trial in 1946–47 convicted many leading Nazi physicians of crimes against humanity with severe punishments including hanging or long prison terms. However, many in the medical profession aligned with these horrors remained in leading positions in the medical community—one even being elected to head the World Medical Association then discussing the Helsinki Declaration of Ethics in Biomedical Research before being forced to resign. The Nuremberg Trials and the subsequent Helsinki Declaration laid the fundamentals of biomedical ethics with regulations and requirements of ethical procedures and the Institutional Research Board, often referred to as Helsinki Committees. These were established by individual research centers, universities, hospitals, and other health care facilities to supervise and approve (or refuse) applications seeking funding, conducting, and publishing research involving human subjects.

The reappearance of genocide in the late twentieth century in the Balkans and Rwanda and in the twenty-first century in Darfur with over 300,000 deaths and 2.5 million displaced persons highlight this as a public health concern and its prevention as a public health and international political responsibility. Incitement to genocide is now considered a crime against humanity and was the basis for trials and convictions of leaders of the Rwandan Tutsi tribe, as well as inciters to ethnic violence and the political leaders and perpetrators of mass murders in the former Yugoslav republic. The threat and practice of genocide is still present, whether it is the murderous raids of Sudanese Janjaweed militias in Darfur and South Sudan, or the threats of genocide by Iran and associated terrorist organizations against Israel and Jews in general, the killing of Christians in northern Nigeria, Muslims in Myanmar and the genocidal civil war in Syria. Incitement to genocide is now accepted as part of international discourse, including the United Nations, which acted to accommodate the Rwanda massacres in 2003.

The risk of “silent” genocide is present in the 21 st century with forced migration, limiting access rights of refugees to host countries, use of chemical weapons against civilian targets, use of starvation, mass rape and abuse of civilian displaced persons, and persecution including mass murder, expulsion, and slavery of minority ethnic, religious and refugee populations.

The UNICEF report of 2017 states: “ 2016 was one of the most dangerous years to be a child in recent memory. Millions of children were threatened and displaced by crises around the world. Millions more faced poverty, deprivation, violence, exploitation and discrimination. ” There are 66 million displaced persons in the world in 2017 who are refugees from war, endemic violence, terror, sexual violence and slavery, ethnic violence, chemical warfare, bombing civilians and medical facilities, hazardous journeys to “safety,” and starvation as a tool of warfare, all forms of genocide. All of this in the 21 st century when “Never Again: was the slogan following the Holocaust and other horrors of the 20 th century.

Genocide represents the most extreme assault on human rights and protection for life. In the 20 th century, an estimated 200 million have perished from genocide. An outline of genocides of the past 100 years is seen in Box 13.2 . The Turkish genocide of Armenians in 1917 was followed by horrific genocides carried out under the flag of communism in Soviet USSR in the 1920s, in the Peoples’ Republic of China under Chairman Mao in the 1950s and the Khmer Rouge in Cambodia in the 1980s, nationalism in the former Yugoslav republics in the 1990s and ethnic hatred in Darfur in the early years of the 21 st century, and in civil war in Syria in the second decade of the 21 st century. Totalitarian dictatorships, past war and defeat, ideologies of exclusiveness, ethnic purity and religious fundamentalism increase risks for genocide. Perpetrators use dehumanizing, demonizing and delegitimizing hate speech to desensitize or intimidate bystanders and to incite, mobilize, order and instruct followers to carry out mass murder.

Eugenics and Genocide: “the Slippery Slope”

Eugenics was a movement within the “Social Hygiene” concept of the early part of the 20 th century. It was widely promoted to improve the population by reducing births among mentally ill and handicapped people. Legislation in some states in the US was upheld in decisions of the Supreme Court.

In 1942, the American Journal of Psychiatry published three articles, one arguing that “feebleminded” people should be killed (i.e., euthanasia). A rebuttal argued against euthanasia. An unsigned editorial position was that “euthanasia” would be appropriate in some cases, and that parents’ opposition to this procedure should be the subject of psychiatric concern. The arguments referred to the context of eugenics and the murder of mental patients in Germany. The editorial pointed out that those genetic theories in psychiatry could be a precursor for future similar proposals. Forced sterilization was also practiced in Canada and Sweden.

This idea was promoted by Hitler in Mein Kampf and adopted by the Nazi party, which was legally elected to office in 1933. Organized massacres of mentally-ill and handicapped children and adults led to practices of various modes of killing, including starvation and gas chambers. These methods were then applied in concentration camps and the Holocaust murder of six million Jews and millions of others.

Genocide represents the most extreme assault on the respect for life. During the 20 th century, an estimated 200 million have died during genocide. Totalitarian dictatorships, past wars and defeat, ideologies of exclusiveness, ethnic purity, and religious fundamentalism increase risks for genocide. Perpetrators use dehumanizing, demonizing, delegitimizing incitement by hate speech and propaganda to desensitize or intimidate bystanders and to promote, organize, order, and instruct followers ready to carry out mass murder. Consider the following list:

• 1915–17: Armenian genocide by Ottoman Turkish Empire—1.2 million killed.
• 1920–40s: Eugenics movement—United States, Sweden, Canada.
• 1920s: Mass executions, deportations, starvation as policy in Soviet Union Stalinist regimes killed millions.
• 1930–40s: Mass sterilization of “defectives” in the US and Sweden.
• 1930–40s: Mass murder of “defectives” in Nazi Germany (750,000).
• 1940s: Quarantining as pretext for ghettos by Nazis.
• 1940s: Concentration camps, human experimentation.
• 1940s: Holocaust; six million Jews and genocide in Nazi occupied Poland and the Soviet Union.
• 1947: Nuremberg Trials; convictions and capital punishment for crimes against humanity, genocide and criminal experimentation on humans by Nazi leaders and medical doctors.
• 1950s: Mass starvation in Maoist China—estimated deaths of 21 million people.
• 1948: Convention on the Prevention and Punishment of the Crime of Genocide.
• 1975–79: Cambodian political genocide of 1.7 million; genocide of Hmong in Laos.
• 1988: Iraqi genocide of Kurds in town of Halabja by poison gas.
• 1988: Brazil genocide of Tikuna people.
• 1992–95: Serbian rape, starvation and massacres in Srebrenica in Bosnia, Croatia and Herzegovina.
• 1994: Rwandan genocide of Tutsi tribe with 800,000 killed over a 100-day period from April to July.
• 2003–12: Sudanese genocide in Darfur (400,000 plus).
• 2011–17: Sudanese genocide of Nuba people.
• 2012–17 Iran incitement to genocide of Israel.
• 2012–17: Syria: Civil war; mass civilian deaths by bombardment and gas, displacement of millions; genocide of Yazidis and Christians.
• 2012–17: Democratic Republic of Congo massacres of Kivu minority; mass violence and refugee flow from South Sudan.
• 2017 Expulsion and mass violence against over 600,000 Rohingya Muslim population of Myanmar.

The UN Convention on Prevention and Punishment of the Crime of Genocide (UNPPCG) of 1948 defines acts committed with intent to destroy, in whole or in part, members of a national, ethnical, racial or religious group as crimes against humanity. The UNPPCG specifies that incitement to genocide is itself a crime against humanity. Legal action should focus on state-sanctioned incitement as a recognized early warning sign. The UNPPCG convention defines genocidal acts including the following as punishable under international law:

• Genocide.
• Conspiracy to commit genocide.
• Direct and public incitement to commit genocide.
• Attempt to commit genocide.
• Complicity in genocide.

Genocide prevention requires international surveillance networks for monitoring and reporting incitement and hate speech in media, textbooks, places of worship, and the internet. Surveillance should monitor and identify the sources, and map their distribution and spread. Dehumanization, demonization, delegitimization, disinformation, and denial are danger signs of potential genocidal actions. Genocide results from human choice and bystander indifference. One lesson of the Holocaust and subsequent genocides is that silence by nations and international organizations constitutes complicity. The public health community has a responsibility to speak out publicly on genocidal threats and its early warning signs (See Box 13.1 ).

Human Experimentation

Human experimentation has been a subject of great concern since the Nazi and Imperial Japanese armed forces’ horrific experiments on prisoners and concentration camp victims during World War II. The Nuremberg trials set forth ten principles of professional responsibility to comply with internationally acceptable medical behavior in regard to research on humans (see Table 13.2 ).

Ethical Issues of Medical Research Derived from the Nuremberg Trials, the Universal Declaration of Human Rights and Declaration of Helsinki

Nuremberg Doctors Trial, 1946–47	The voluntary consent of a human subject is absolutely essential, with the exercise of free power of choice without force, fraud, deceit, duress, or coercion
	Experiments should be such as to bear fruitful results, based on prior experimentation and the natural history of the problem under study. They should avoid unnecessary physical and mental suffering
	The degree of risk should not exceed the humanitarian importance of the experiment
	Persons conducting experiments are responsible for adequate preparations and resources for even the remote possibility of death or injury resulting from the experiment
	The human subject should be able to end his participation at any time
	The scientist in charge is responsible to terminate the experiment if continuation is likely to result in injury, disability, or death
Universal Declaration of Human Rights, 1948	Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services
Declaration of Helsinki, 1964	Research must be in keeping with accepted scientific principles, and should be approved by specially appointed independent committees
	Biomedical research should be carried out by scientifically qualified persons, only on topics where potential benefits outweigh the risks, with careful assessment of risks, where the privacy and integrity of the individual is protected, and where the hazards are predictable. Publication must preserve the accuracy of research findings
	Each human subject in an experiment should be adequately informed of the aims, methods, anticipated benefits, and hazards of the study. Informed consent should be obtained, and a statement of compliance with this code
	Clinical research should allow the doctor to use new diagnostic or therapeutic measures if they offer benefit as compared to current methods
	In any study, the patient and the control group should be assured of the best available methods. Refusal to participate should never interfere with the doctor–patient relationship. The well-being of the subject takes precedence over the interests of science or society

Note: Summarized from the Nuremberg Trials (1948) and World Medical Association, Declaration of Helsinki.

The Helsinki Declaration was first adopted by the World Medical Assembly in 1964, and amended in 1975, 1983, 1989, 1996, and 2013. It delineates standards of medical experimentation and requires informed consent from subjects subjecting themselves to medical research. These standards have become the international norm for experiments, with national-, state-, and hospital-Helsinki committees regulating research proposals within their jurisdiction. Funding agencies require standard approval by the appropriate Helsinki committee, sometimes called Institutional Review Boards (IRBs) or Ethical Review Boards (ERBs), before considering any proposal, with informed consent on any research project. The process recognizes that medical progress is based on research that must include studies involving human subjects, but medical research is subject to ethical standards that promote and ensure respect for human subjects and protect their health and rights. The key issues examined include:

• Research objectives should outweigh the risks and burdens to the research subjects.
• Research should conform to generally accepted scientific principles and literature.
• Participants are volunteers.
• Informed consent must be obtained including warning of potential risks.
• Risks are minimized and monitored.
• Respect for privacy and confidentiality.
• Respect for human rights.
• Scientific integrity.
• Social solidarity and paternalism.
• Fairness and equity.
• If the results are definitively positive, the research should be stopped.

The Tuskegee experiment (see Box 13.3 ) conducted in Alabama from 1932 to 1972 by the US Public Health Service (USPHS) was a grave and tragic violation of medical ethics. It was initiated in the context of the 1930s and consistent with widespread and institutionalized racism, detached from humanist values and historical medical ethics of “first, do no harm.” The Tuskegee experiment, and a following similar study conducted by the USPHS in conjunction with the Ministry of Health in Guatemala, are remembered as important ethical transgressions which have had repercussions until the present time resulting in suspicion of public health endeavors, particularly among the African-American community in the US, even after a public apology in 1997 by then president Bill Clinton.

The Tuskegee Experiment

The Tuskegee experiment was carried out by the US Public Health Service between 1932 and 1972. It was meant to follow the natural course of syphilis in 399 infected African-American men in Alabama and 201 uninfected men. The men were not told that they were being used as research subjects. The experiment had been intended to show the need for additional services for those infected with syphilis. However, when penicillin became available in 1942, the researchers did not inform or offer the men treatment, even those who were eligible when drafted into the army in 1942. The experiment was stopped in 1972 as “ethically unjustified” when the media exposed it to public scrutiny.

The case is considered unethical research practice because, in the time it was conducted, it did not provide the patients with information on the research nor on the availability of curative care when it became available. The patients’ well-being was put aside in the interest of a descriptive study.

A similar experiment was conducted by the US Public Health Service in full cooperation with the Guatemala Ministry of Health during 1946–1948 in which soldiers, prisoners, and others were deliberately exposed to prostitutes known to be infected with syphilis. This experiment was terminated when it was revealed in the US media by a historian.

In 1997, President Bill Clinton apologized to the survivors and families of the men involved in the experiment on behalf of the US government. The Tuskegee experiment is the source of widespread lingering suspicion of public health in the African-American community to the present time.

Ethics in Public Health Research

The line between practice and research is not always easy to define in public health, which has surveillance of population health as one of its major tasks. This surveillance is mostly anonymous, but relies on individually identifiable data needed for reportable and infectious disease control as well as for causes of death, birth defects, mass screening programs, and other special disease registries. It may also be necessary to monitor the effects of chronic disease, for example, to ascertain repeat hospitalizations of patients with congestive heart failure to assess the long-term effects of treatment, and the effects strengthening ambulatory and outreach services to sustain chronic patients at a safe and functional level in their own homes.

Preventive care practices—e.g., sanitation, healthy and safe food and diets, health promotion, immunizations, prenatal care, newborn screening, Pap smears, mammography, and colonoscopies—as well as access to medical care and hospital utilization, are all part of public health. Monitoring and impact assessment of preventive programs may require special surveys, such as those conducted by the US National Health and Nutrition Studies (NHANES) and are important to assess health and nutritional status as well as other measures of health status and risk factors such as smoking and exercise. Every effort in public health research must be made to preserve anonymity and privacy for the individual, but in some cases such as reporting of contagious diseases or birth defects, case contact is crucial. This can entail identifying people who attended an event or were on an airplane where an infected person may have been — such as with measles or antibiotic resistant tuberculosis — so as to take appropriate preventive measures.

The general distinction between research and practice has to do with the intent of the activity. Clinical research uses experimental methods to establish the efficacy and safety of new or unproven interventions; many drugs and procedures in common use have never been subjected to randomized controlled trials. In practice, many methods are devised that are held to be effective and safe by expert opinion and documented as such. Researchers comparing HIV or hepatitis B transmission rates among intravenous drug users not using needle exchange programs would be doing unethical research, according to accepted current standards, by giving safe needles to the experimental group and withholding them from the control group. The scientific justification of an experiment must be made explicit but would not likely be approved by an Ethical Review Board (Helsinki Committee). In some cases of new therapy for life threatening conditions, the FDA will “fast track” what are called “orphan drugs” urgently needed as happened with the NIH recommendation for antiretroviral (ART) drugs for HIV/AIDS. This turned out to be a major success for treatment and prevention of HIV (Faucci, 2014). Clinical equivalence is a necessary condition of all clinical and public health research and provision of standard of care treatment to control groups is a minimal requirement for most research ethics boards. Determination of the standard, and whether it should be place, time, and community specific, is an area of ongoing controversy.

A 1996 US Public Health Service study supported by the US National Institutes of Health (NIH) and WHO compared a short course of zidovudine (AZT) to a placebo given late in pregnancy to HIV-positive women in Thailand, measuring the rate of HIV infection among the newborns. The experiment was terminated when a protest editorial appeared in a prominent medical journal. This study confirmed previous findings that AZT given during late pregnancy and labor reduced maternal-fetal HIV transmission by half. The findings indicate that AZT should be used in developing countries, and the manufacturers agreed to make it available at reduced costs. The result has been a major success with more recent medications to reduce maternal–fetal transmission of HIV in many places in Africa with important financial and professional support from the Global Alliance for Vaccine Initiatives (GAVI), international donors, and a slowing of the spread of HIV- and AIDS-related deaths.

An outstanding case of breach of ethics in public health research occurred with the “Wakefield Effect” as described in Box 13.4 . The importance of responsible medical journalism to keep a watchful eye on the possibilities of misleading scientific publications is of great importance for the ethical and legal aspects of public health.

The Wakefield Effect

In 1998, one of the top medical journals in the world, Lancet , published an article by a number of well-known researchers headed by Dr. Andrew Wakefield. The article reported on 12 cases of autistic children and allegedly showed a connection to immunization with MMR vaccine (measles-mumps-rubella).

The immediate effect of this “revelation” was widespread alarm in the United Kingdom and abroad concerning MMR vaccine and a drop in immunization coverage with measles-containing vaccines in the United Kingdom and elsewhere. This was mainly triggered by mothers refusing to have their child vaccinated with the “risk of autism”. As a result, measles epidemics occurred in the United Kingdom and in many other countries with the disease again becoming endemic in many parts of Europe and spreading to North and South America by travelers and tourists.

After a long series of investigative journalism in the British press, the article came under scientific scrutiny and the withdrawal of many of the coauthors, but consistent insistence by the lead author of its authenticity. Coauthors admitted to having been credulous and insufficiently vigilant in agreeing to be associated with the paper. British medical authorities later found Dr. Wakefield guilty of medical fraud and the UK General Medical Council withdrew his license to practice medicine. In 2000, 12 years after the original publication, Lancet formally withdrew the article. This fraudulent scientific publication caused a serious loss of the credibility of immunization in general, and especially regarding MMR vaccine, one of the greatest life savers of public health.

The return of measles in Europe to endemicity with frequent international transmission, fostered loss of confidence by mothers in immunization. Measles-containing vaccines were particularly affected due to the publicity given to the Wakefield case and issues of scientific integrity. Fraud and conflict of interests were proven in this case. The journal editors failed to ensure the scientific integrity of the lead author and coauthors, and were negligent in failure of the journal to retract fraudulent and disproven publications in real time, instead of waiting 12 years after publication.

In other public health issues, single publications of findings of small sample and poorly assessed studies published in haste without adequate critical review occur frequently. In electronic media, the problem of disinformation provokes great anxiety and rejection of well-established successful public health interventions such as fluoridation, and folic acid fortification of flour, with unsubstantiated and disproven claims that they may cause cancer, asthma, and other ill effects.

The interface between ethics, law, and science in public health requires continuous sensitivity to the downstream effects of reducing public trust and reduced parental compliance with immunization of their children and putting other children at risk.

Current Relevance

A preeminent ethical issue in public health is that of assuring universal access to services, and/or the provision of services according to need. While all industrialized countries except the United States have universal health care insurance or national health service evolving since the 19 th century (see Chapter 8); the United States is still struggling with the issue in the 21 st century. The solidarity principle of societal shared responsibility for funding universal access to health care is based on equitable prepayment for health care for all by nationally regulated mechanisms through place of work or general revenues of government. A society may see universal access to health care as a positive value, and at the same time utilize incentives to promote or place limits on use of services or benefits to the individual such as hospital care, immunization, screening programs, prescription drugs and others. Some services may be arbitrarily excluded from health insurance, such as dental care, although this is to the detriment of children and a financial hardship for many. Strategies for program inclusion are often based on historical precedent rather than cost-effectiveness or evidence. While efforts are being made to include more children in the program, the Medicaid system in the US defines eligibility at income levels up to 133 percent of the poverty line, thus excluding a high percentage of the working poor. This is a topic of current and continuing political importance in electoral platforms in the US to address the challenge of the uninsured and poorly insured working poor population (i.e., Obamacare versus Trumpcare). Health is also a political issue in countries with universal health systems where funding may be inadequate or patient dissatisfaction common.

The HIV/AIDS epidemic which appeared suddenly in the early 1980s and became a global pandemic in 1990s raised a host of medical and public health ethical issues. Management of the epidemic was in some respects in conflict with the long-established role of public health of contacting and quarantining persons suffering from selected communicable diseases. It was not acceptable or feasible in modern society to require follow-up of case contacts or to isolate HIV carriers, at a time when there was no clinical cure with medications. However, this led to failure or delay of public health authorities, even in the late 1980s, to close public bathhouses in New York and other US cities where exposure to multiple same-sex partners promoted spread of a lethal disease, which could have been interpreted as negligence. During the 1980s, the politics of HIV/AIDS in the US centered on concerns in the community of men who have sex with men (MSM) that HIV testing could be used in a discriminatory manner. AIDS was initially addressed as a civil liberties issue and not as a public health problem. Screening, reporting, and case contact follow-up were seen as an invasion of privacy and counterproductive by increasing resistance to and avoidance of testing.

In these political circumstances, the educational approach was adopted as most feasible and acceptable. The AIDS epidemic and public anxiety about contracting AIDS through casual sexual contact reinforced the need for public education on safe sex. This has been raised as an ethical issue because such education may be construed as condoning teenage and extramarital relations. The issue of HIV screening of pregnant women in general or in high-risk groups took on a new significance with the findings that treatment of the pregnant woman reduces the risk of HIV infection of the newborn, and that breastfeeding may be contraindicated.

A similar issue arose anew in the past decade in the context of using the new human papillomavirus (HPV) vaccine for prevention of cancer of the cervix. Initially the vaccine was recommended for preteen girls to create protective antibodies to the virus before they became sexually active to prevent the possibility of sexually transmitted infection of the virus. Controversy arose over concern that this immunization of young girls might promote early onset of sexual activity. Gradually acceptance increased and other age groups of women were urged to take the vaccine. Boys were added to the recommended immunization target groups so as to reduce transmission of the virus, and to address male-to-male transmission via oral and anal sex. Inclusion of HPV vaccination requirement for school entry is under debate in the US, but parental refusals are increasing. CDC reports that HPV infects a large proportion of people in the US. Among adults aged 18–59 it was 45 percent in men and 40 percent in women. Nearly 10,000 women in the US are diagnosed with cervical cancer each year and 3,700 women die. Cancer of the cervix has been massively reduced by routine Pap smears for early case-finding and treatment. The advent of an effective HPV vaccine promises to lower cancer of cervix rates even further. The disease is much more common in low-income countries where screening and HPV immunization are still very low on the health priorities list, so that cervical cancer is the second leading cancer killer of women worldwide. A recent survey conducted by the American Academy of Pediatrics result indicated that nearly 90 percent of pediatricians reported that they experienced parental vaccine refusals in 2013 compared to 75 percent in 2006. The vaccines most likely to be refused, mainly due to misinformation, are HPV, influenza, measles, mumps, and rubella vaccines, all strongly recommended by public health and clinicians.

Choices in health policy are often between one “good” and another. Limitations in resources may make this issue even more difficult in the future, with aging populations, increasing population prevalence of physical disabilities, and rapid increases in technology and its associated costs. For example, the UK’s National Health Service at one point refused to provide dialysis to persons over age 65. When computed tomography (CT) was first introduced, Medicare in the US refused to insure this service as an untested medical technique. Due to a lack of facility resources such as incubators and poor prospects for the survivors, the Soviet health system considered newborns as living only if they weighed over 1,000 grams and survived more than seven days. Those under 1,000 grams who would be considered living by other international definitions, would be placed in a freezer to die. At the opposite extreme, many western medical centers use extreme and costly measures to prolong life in terminally ill patients, preserving life temporarily, but often with much suffering for the person and at great expense to the public system of financing health care.

In many countries, such as those in the former Soviet system, spending for hospital services, in some cases was grossly overemphasized and in excess of need, accompanied by lack of funds for community care such as adding new vaccines for the immunization program for children, although coverage rates were high. In the US, there was a lack of funds for immunization of poor children, but this has gradually improved over the past decade with changes in health insurance for the poor as well as by using food supplement programs to promote immunization.

Research Misconduct

The Office of Research Integrity of the US Department of Health and Human Services defines research misconduct as: “fabrication, falsification, or plagiarism in proposing, performing, or reviewing research, or in reporting research results:

• Fabrication is making up data or results and recording or reporting them.
• Falsification is manipulating research materials, equipment, or processes, or changing or omitting data or results such that the research is not accurately represented in the research record.
• Plagiarism is the appropriation of another person’s ideas, processes, results, or words without giving appropriate credit.
• Research misconduct does not include honest error or differences of opinion.”

The prevalence and publication of erroneous information and compromised research findings is an ongoing issue in the 21 st century, which can spread false information in the media such as the internet. This can have serious negative consequences for population health. Pseudoscience can feed populist movements with tragic consequences in public health.

Helsinki Research Ethics Committees (or Institutional Review Committees) are responsible to ensure that ethical principles are maintained in research proposals and publication of results of such research. These principles include informed consent, confidentiality, and scientific integrity. Publication in peer-reviewed journals is essential for establishing and advancing the evidence base for public health practice. Poor, or fraudulent science, can have a substantial adverse impact on public opinion both on health issues and on the priorities in the allocation of resources. It is essential that journal editors and reviewers adhere to high ethical and professional standards. They must be vigilant to avoid allowing poor professional standards of articles to be published or allowing non-professional factors or conflicts of interest to distort decision-making processes. Professional integrity and high scientific standards are vital to advance public health practice.

Ethics in Patient Care

Ethical issues between the individual patients and health care providers are important in health systems. A doctor is expected to use diligence, care, knowledge, skill, discretion, and caution in keeping with practice standards accepted at the time by responsible medical opinion, and to maintain the basic medical imperative to “do no harm” to the patient. Patients should have the right to free choice of provider and treatment, to observance of quality standards, access to high quality health services, to be informed of his or her condition, give informed consent, to confidentiality of personal and health information, and to physical privacy during care and diagnosis, to available alternatives for treatment, to be informed of the risks and benefits involved, and to complain and seek compensation for negligence. Ideally, patients have the right of access to high quality health services, to safety and freedom from harm caused by lack of resources, geographic inequality, poor functioning of health services, and from medical malpractice and errors. Patients’ rights include the right of access to innovative procedures, including diagnostic procedures, according to international standards and independent of economic or financial considerations. Patients may seek alternative medical opinions, but this right is not unlimited, as any insurance plan or health service may place restrictions on payment for further opinions and consultation without the agreement of a primary care provider, which is called “the gatekeeper” role.

Health insurance providers have responsibility beyond that of payment for health service and individual care by a physician, in institutions, or through services in the community or the home. The contract for service is becoming less between an individual physician and the patient, but increasingly among a health system provider group staff and a client. This places a new onus on the physician to ensure that patients receive the care they require. Conversely, the US provider often faces the dilemma of knowing that a patient may not access needed services because of a lack of adequate health insurance, and the terrible practice of exclusions due to “prior health conditions”.

Sanctity of Life Versus Euthanasia

The imperative to “save a life” is an important ethical and practical issue in health care. Principles of physician-assisted euthanasia were based on a legal process including psychiatric assessment. Physician-aided suicide of a patient is facilitated by providing the means or information—e.g., indication of a lethal medication dosage—provided by a physician who is aware of the patient’s intent. Both are based on the right of the patient to decide to die with dignity when their illness is terminal and the individual is suffering excessively. This is not a medical decision alone. It is also an agonizing issue for society to address.

The Nazi euthanasia program in Germany in the 1930s and its subsequent application as mass extermination in the Holocaust with grossly unethical human experimentation provided the direst of warnings to societies of what may follow when the principle of the sanctity of individual human life is breached. The issue, however, returned to the public agenda in the 1980s and 1990s as advances in medical science have allowed the prolongation of human life beyond hope of recovery.

Legislation in the Netherlands, Belgium, the US (“assisted suicide” in six US states, Washington DC, Oregon, Vermont, California, Colorado, and Montana as of April 2017), northern Australia and Canada legally sanctioned passive euthanasia (i.e., withdrawing medical assistance) with various safeguards in a variety of circumstances, such as long-term comas or late stages of terminal illnesses. The legislation in Canada, known as “dying with dignity”, is the federal regulatory framework with strict criteria for eligibility and procedures, provides for medical assistance in dying for those persons with a “grievous and irremediable medical condition; they have made a voluntary request for medical assistance in dying that, in particular, was not made as a result of external pressure; and they give informed consent to receive medical assistance in dying after having been informed of the means that are available to relieve their suffering.” The person must be eligible for government-funded health services and be over 18 years. Doctors, patients, relatives, and health care organizations need clear guidelines, orientation, procedures, legal protection, and limitations where failure to take the utmost steps to “save” the patient by intubation, resuscitation, or transplantation may cause legal jeopardy. Protection of the elderly or chronically ill from malicious application of this form of merciful death must ensure that it is truly the patients’ wish. This requires well defined procedures with legal, social, psychiatric and medical participation.

Even though a distinction can be drawn theoretically between permitting and facilitating death, in practice, doctors in intensive care units face such decisions regularly where the line is often blurred. Hospital doctors routinely take extreme measures to prolong the life of hopeless cases. Such decisions should not be considered for economic reasons alone, but in practice the costs of care of the terminally ill will be a driving force in debate of the issue. Living wills allow a patient to refuse heroic measures such as resuscitation, with “do not resuscitate” standing orders and assignment of power of attorney to family members to make such decisions. Family attitudes are important, but the social issue of redefining the right of a patient to opt for legal termination of life by medical means will be an increasingly important issue in the 21 st century.

The Imperative to Act in Public Health

As in other spheres of medicine and health, in public health the decision whether to intervene in an issue is based on identification and interpretation of the problem. A case must be made of importance even if a rare condition, establishing evidence of the potential of the intervention to improve the situation, to do no harm, and to convince the public and political leaders of the need for such intervention along with the resources to carry it out. This process requires patience and a longer time frame than many other fields in health.

Some interpretations of ethics in health consider that the only purpose for which power can be rightfully exercised over any member of a democratic community, without asking individual permission and possibly against their will, is to prevent harm to others. However, this is a dictum that is not always applied to public health, which is obliged to act to protect health in so many spheres such as water, sanitation, food and drug safety, and environmental health on a spectrum that extends to banning smoking in public places, mandating food fortification, and many other areas for improved population health in a civil society.

Failure to act is an action, and when there is convincing evidence of a problem that can be alleviated or prevented entirely by an accepted and demonstrably successful intervention, then the onus is on the public health leader/authority to advocate such action and to implement it as best as possible under the existing conditions. Failure to do so is a breach of “good standards of practice” and could be unethical. Inertia of the public health system in the face of evidence of a demonstrably effective modality such as adoption of state-of-the-art vaccines or fortification of flour with folic acid to prevent birth defects would come under this categorization and may even constitute neglect and unethical practice. This is not an easy categorization because there is often disagreement and even opposition to public health interventions, as was the case in opposition to vaccination long after Jenner’s crucial discovery of this procedure in the late eighteenth century. This idea is also a significant problem true today with opposition to many proven measures such as immunization, fluoridation or fortification of basic foods. Box 13.5 shows the ethical standards of the American Public Health Association of 2002.

Principles of Ethical Public Health Practice: American Public Health Association, 2002

1. Public health should address the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.
2. Public health should achieve community health in a way that respects the rights of individuals in the community.
3. Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members.
4. Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all.
5. Public health should seek the information needed to implement effective policies and programs that protect and promote health.
6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation.
7. Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public.
8. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community.
9. Public health programs and policies should be implemented in a manner that most enhances the physical and social environment.
10. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the likelihood of significant harm to the individual or others.
11. Public health institutions should ensure the professional competence of their employees.
12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.

The problem of refusals of vaccination has become an issue in the US mainly among upper middle class families. In Western Europe delay in updating immunization programs such as the two doses of measles policy in the past has created a situation of measles outbreaks across Europe since 2010 with many cases among unimmunized children or among young adults or those with only one dose and waning immunity. In many low- and medium-income countries funding levels for health are minimal leading to the delay in professional or governmental acceptance of “new” vaccines. This has been a serious issue but international donors have helped countries in sub-Saharan Africa to expand the range of vaccines in their routine programs with important life saving vaccines such as rotavirus and hemophilus influenza B. Underfunding for health is an ethical dilemma in many low- and medium-income countries. In former Soviet countries including the Russian Federation much of the overall low level of funding for health is due to their declining, but still relatively high, acute-care hospital bed supply with much longer average length of hospital stay leaving primary care and upgrading of immunization lagging.

Closure of hospitals involves difficult political and ethical decisions and is a source of dispute between central health authorities, the medical professions, and local communities. Health reforms in many industrialized countries, such as reducing hospital bed supplies, managed care systems, promoting cost containment, and reallocation of resources raise ethical and political issues often based on vested interests such as private insurance systems, hospitals, and private medical practitioners (see Chapters 8 and 15Chapter 8Chapter 15).

Where there is a high level of cumulative evidence from professional literature and from public health practice in “leading countries” with a strong scientific base and case for action on a public health issue, when does it become bad practice or even unethical public health practice to ignore and fail to implement such an intervention? Such ethical failures occur frequently and widely. For example, is it unethical to not fortify grain products with folic acid and salt with iodine when there is overwhelming evidence of safety and cost effectiveness? Should there be a recommended European immunization program; should milk be fortified with vitamin D; should vitamin and mineral supplements be given to pregnant and lactating women, and children; should all newborns be given vitamin K intramuscularly routinely? Other examples include the issues of fluoridation of water supplies and opposition to genetically modified crops or generic drugs in African countries. These issues are continuously debated and the responsibility of the trained public health professional is to review the international literature on a topic and formulate a position based on the cumulative weight of evidence. It is not possible to wait for indisputable evidence because in epidemiology and public health, this rarely occurs. This is another reason that guidelines established by respected agencies and professional bodies free from financial obligations to vested interest groups are essential to review evidence which accumulates on a continuing basis on many issues thought to have been resolved or which appear de novo.

A recent public health issue has been the banning of trans fats in baking and cooking, with legislation in New York City and some upstate New York State counties. The US Food and Drug Administration (USFDA) has declared trans fats, found in many popular processed foods, like baked goods and frozen foods, to be unsafe for consumption as they contribute to heart disease. The USFDA promotes manufacturer compliance and will regulate banning of use of trans fats by 2018, which is expected to reduce coronary heart disease and prevent thousands of fatal heart attacks every year. The USFDA reports that between 2003 and 2012, consumer trans fat consumption decreased about 78 percent and that the labeling rule and industry reformulation of foods were key factors in informing healthier consumer choices and reducing trans fat in foods. While trans fat intake has significantly decreased, the current intake remains a public health concern. The Institute of Medicine (IOM) recommends that consumption of trans fat be as low as possible while consuming a nutritionally adequate diet.

The WHO European Region reports that five European countries are in the process of banning trans fats through regulation, while others have decided to use self-regulatory mechanisms. On the other hand, virtually no countries in the European Region fortify flour with folic acid to prevent birth defects (neural tube defects), a lapse in current international public health standards. Along with rising incidence of rickets in infancy due to lack of sun exposure and lack of vitamin D supplements in pregnancy care, birth defects and severe rickets are increasing especially among dark skinned mothers in full body clothing for religious reasons. Most consumers do not know that some processed food categories contain large amounts of trans fats. Consumption in some population groups, particularly poorer people, can be very high. Removing trans fats from the food supply is one of the most straightforward public health interventions for reducing the risk of cardiovascular diseases and some cancers, and improving diets. A study comparing myocardial infarctions in New York counties that banned trans fat usage to counties that did not showed a greater reduction in acute myocardial infarctions in the counties that had banned trans fats. The ethical issue will be to see the rate of acceptance of this finding in other jurisdictions versus traditional opposition to too much interference by the state. The same issue regarding folic acid fortification of flour to reduce birth defects is similarly both a professional and ethical question. Virtually all European countries have ignored the evidence and fail to adopt mandatory fortification thus harming poorer population groups with less money to buy healthier foods. The delay in implementation of proven safe and effective public health measures is one of the key ethical issues in public health practice.

Ethical Issues

Coleman et al. discuss global issues in public health ethics with emphasis on disparities in health status; access to health care and the benefits of medical research; responding to the threat of infectious diseases; efforts to contain the spread of infectious diseases; international cooperation in health monitoring and surveillance (e.g., International Health Regulations); exploitation of individuals in low-income countries; health promotion, participation, transparency, and accountability. The global Millennium Development Goals (MDGs) and the follow-up Sustainable Development Goals (SDGs) reflect a consensus on objectives and a respectable degree of international support by donor countries. Strong networks such as the Global Vaccine Alliance involve international organization (e.g., WHO, UNICEF, World Bank), donor countries and private donors (e.g., Bill and Melinda Gates Foundation, Carter Foundation, Rotary Club and many others), with a strong track record of mobilizing funds and cooperation with private industry to raise immunization coverage and inclusion of new vaccines in many low income countries and in NTD elimination programs.

Recent public health emergencies involving anthrax, severe acute respiratory syndrome (SARS), Ebola, and Zika viruses have been declared “public health emergencies” and dramatized the need for restrictive public health measures. These include quarantine, isolation, and rationing of vaccines in short supply. Policy-makers and front-line care providers face difficult ethical questions in such cases which can be expected to occur with new challenges in the future. Support during the Ebola outbreak in West Africa in 2014–16 and Zika spreading out from Brazil in 2016–17 has been criticized as bumbling and inadequate, but did indicate strong levels of international cooperation and shared global concern. This most recent Ebola epidemic was the longest and most deadly in history, resulting in nearly 29,000 cases and over 11,000 deaths in Guinea, Liberia, and Sierra Leone. Several potentially useful therapeutic agents were available in 2014 that had been tested on animals, and limited early studies of the safety of vaccine candidates for humans. However, the affected countries struggled to deal with the rapidly escalating epidemic and the growing number of patients. Médecins sans Frontiére (MSF) provided the front-line treatment and infection control, and warned that the epidemic was “out of control” and would require a massive international response. First responders in many settings show the way in ethical behavior in calamitous situations such as the Syrian civil war where civilians as well as medical facilities are bombed and gassed deliberately by government and foreign forces.

National, international, and local representatives play a critical role in preparing the global community for unexpected epidemics. Research, with sound clinical trials based on best practices for improving clinical care and vaccines for prevention to protect at risk populations, are needed during and between public health emergencies. Research efforts to develop vaccines for these emerging infectious diseases and others such as malaria and dengue are impressive and will hopefully bring forth lifesaving vaccines on large scales in the coming decade. In the case of Ebola, none of the clinical trials have reached definitive conclusions about efficacy in the search for therapeutics, but vaccine trials have identified vaccines that are safe and effective. The availability of financial, organizational, and professional resources to tackle such issues is an underlying problem of priority decision-making with professional, ethical, and moral standards.

Public health may face the challenge of pandemic influenza—such as the avian flu—with decisions regarding allocation of vaccines, treatment of massive numbers of patients arriving at hospitals in acute respiratory distress with very limited resources to cope, coping with sick or absent staff, and many other issues such as not only individual life-and-death situations, but large scale mortality. The ethical questions will be replaced by struggles to cope. Preparation for such potential catastrophic events will be a challenge to public health organizations and the health system generally.

Public health is tasked with monitoring population health and implementing measures to reduce morbidity or mortality of the population within ethical norms of societal acceptability. Advancing public health goals, with minimal restriction of individual liberties, will reduce the burden of disease and mortality, while reducing inequities and advancing social justice. This requires trained professionals to monitor population-based data and research with translation of new science into practice. Programs to achieve these objectives must be evidence-based to substantiate that they will achieve these goals with minimal restrictions, but with public support for those vital to ethical and successful public health.

Teaching Public Health Ethics

The aim of ethics education in public health should be to enhance the ability of public health professionals, policy makers and citizens to reason rationally about the moral dilemmas and value conflicts inherent to human rights, social justice, and the application of knowledge and technology in the health sciences and in public health measures.

Ethics analysis typically involves the capability to identify the public health issue and its contribution to health of the population. This requires a review of the professional literature to know the state-of-the-art techniques and to be able to articulate the factual information to the decision-makers and the public. This requires identification of the ethical issues of the case and to identify the “stakeholders”—those whose rights and interests will be most directly affected by the decisions made and the values, concerns, and information at stake in the case. The ability to identify options available to decision-makers in the case is vital to making the “case for action” and the decision-making process, before, during and after a public health event or process as in pandemic preparedness. The cost of action versus inaction is a vital factor.

Training current faculty on public health ethics issues should be mandatory in schools of public health in order to incorporate ethics into existing courses of formal educational programs. This requires specific and mandatory courses on public health ethics along with incorporation of discussion of ethical issues in core courses in the program.

Defining and applying ethical and high standards of practice of medical care as well as public health requires an ideological commitment to individual and community sanctity of life. Ethics in health also requires commitment to advancement of health care and use of best practices of international standards to the maximum extent possible under the local conditions in which the professional is working. This is not an easy commitment as there is often dispute and outright hostility to public health activities in part because of past ethical distortions of great magnitude. But this is an optimistic field of activity by virtue of the great achievements it has brought to humankind. Preparation for disasters and unanticipated health emergencies can raise issues of security, quarantine, isolation, rationing of vaccines due to insufficient supplies—e.g., in influenza epidemics—or restrictions on community events or family burials as in the case of Ebola in West Africa in 2014–16.

Public health also faces slow responses to advances in the science of vaccines or in health promotion measures with proven efficacy. Addressing current issues is a vital part of the “New Public Health” and our ethical and professional commitments. The role of public health in climate change is both a professional and ethical issue, as are many other topics such as food fortification, fluoridation of community water supplies, access to birth control and other longstanding and new topics. Advancement in global health requires consensus of national governments and international bodies working together to alleviate poor health conditions with available professional standards and resource mobilization to achieve this goal. Most issues in public health have ethical aspects so that education on future public health requires adequate attention to the topic, perhaps best presented in case studies.

Ethical issues in public health include both definition of, and decisions to act on a problem, but also delay, avoidance, or inaction when best evidence available indicates action prevents harm to the population. Failure to act in a timely fashion or to allocate resources to meet clear health needs of a population can be unethical just as much as acting in a harmful way. While resource allocation is a political decision, failure to act can be as injurious and unethical as being directly responsible for harmful acts. Public health as a profession and a movement or ideology must be willing to point out the effects of nonaction as well as of ethical or nonethical acts. Compliance with evil is unethical and the preparation of public health workers requires understanding of how to differentiate, and to how to advocate for the better choices in policy and its implementation.

Recommendations

1. Ethics should be incorporated in all courses in public health as well as health policy and management programs.
2. Dedicated courses in ethics should be included in public health education curricula to provide interested students with an opportunity for more in-depth study.
3. Public health ethics along with public health law should be included in criteria for curricula as “cross cutting” courses required by accreditation agencies.
4. Public health ethics orientation workshops should be provided to help teachers in all topic areas of the curriculum, core and elective, incorporate ethics in their teaching material.
5. The topic of public health ethics should be incorporated in ongoing educational programs for practitioners in the broad multi-disciplinary fields of public health.
6. Public awareness and engagement efforts that accompany public health programs and interventions should incorporate some measure of ethics education.
7. Critical thinking about the values involved in a public health controversy is vital to combat the public health problem in question.
8. Recognition that the concepts of social solidarity and obligations as well as individual rights are fundamental in public health practice.
9. Recognition that emergency preparedness and response includes mandatory immunizations such as measles and other public health measures as in influenza or cholera control immunization.
10. Training in ethical studies should be part of public health training at all levels including continuing education.
11. Curriculum development should include awareness of ethical issues of artificial and natural catastrophes of the past century as well as current topics.
12. Case studies are valuable teaching tools and incorporated and examined in class discussion.
13. Teachers of other aspects of public health including epidemiology and health promotion should include ethics in their syllabi and course content.
14. Consideration should be given to development of Helsinki Committee procedures and review criteria for public health-related research based on data sets without individual identification in public health research proposals.
15. Teachers of ethics in public health should have dual training in public health and ethics.

Student Review Questions

1. Why was eugenics a popular topic in western countries among intellectuals during the early part of the 20 th century?
2. How was eugenics practiced in liberal democratic countries?
3. How did the eugenics idea become translated into mass murder of the handicapped in Germany, and then adapted to genocide of Jews and others in the Holocaust?
4. Why is incitement to genocide seen as a precursor and crime against humanity?
5. Why is approval of a “Helsinki Committee” needed before applying for a research grant?
6. Why is assisted death permitted in some jurisdictions, and what steps are needed to ensure this is solely based on the patient’s wishes?
7. Discuss the ethics of requiring children to be fully immunized before they can attend school.
8. What is the “Wakefield Effect”, and how is it affecting attitudes to immunization?
9. How should practicing doctors and public health explain mandatory chlorination, and fluoridation of community water supplies?
10. Is banning cigarette smoking in public places an infringement of individual rights?
11. Is parental refusal of immunization without a valid medical reason ethical?
12. Discuss what you think are ethical issues in public health.
13. Discuss what you think are ethical issues in medical practice.
14. Discuss public health ethics issues in global health.
15. Discuss ethical issues in medical and public health research.
16. Describe the historical and current meaning of the Nuremberg Trials, the Universal Declaration of Human Rights, the Helsinki Declaration and the Tuskegee experiments on public health and medical research ethics.
17. Discuss the role of the news and social media in investigation of public health issues and in spread of “pseudoscience” disinformation on public health topics such as vaccination, fluoridation, and food fortification.
18. Describe the lasting implication of the Tuskegee experiment for attitudes towards the public health profession in the US.

* This case report is largely derived and modified from Tulchinsky T.H., Varavikova E.A., The new public health, 3rd edition. Academic Press/Elsevier: San Diego, 2014, chapter 15 pages 804–816.

HHS Announces Cost Savings for 64 Prescription Drugs Thanks to the Medicare Rebate Program Established by the Biden-Harris Administration’s Lower Cost Prescription Drug Law

Under President Biden’s Inflation Reduction Act, some people with Medicare will pay less for some Part B drugs if the drug’s price increased faster than the rate of inflation.

The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), today announced that some Medicare enrollees will pay less for 64 drugs available through Medicare Part B. The drugs will have a lowered Part B coinsurance rate from July 1, 2024 – September 30, 2024, since each drug company raised prices faster than the rate of inflation. Over 750,000 people with Medicare use these drugs annually, which treat conditions such as osteoporosis, cancer, and infections. White House Domestic Policy Advisor Neera Tanden will announce the cost savings on these life-saving drugs in a keynote address on the Biden-Harris Administration’s focus on lowering costs today at the Center for American Progress.

“Without the Inflation Reduction Act, seniors were completely exposed to Big Pharma’s price hikes. Not anymore. Thanks to President Biden and the new Medicare inflation rebate program, seniors are protected and benefitting from lower Part B drug costs,” said White House Domestic Policy Advisor Neera Tanden. “The Biden-Harris Administration will continue fighting to bring down the cost of health care and prescription drugs for all Americans.”

“President Biden’s Medicare prescription drug rebate program is putting money back in the pockets of seniors and people with disabilities, said HHS Secretary Xavier Becerra. “President Biden made lowering prescription drug costs for Americans a top priority, and he is delivering on that promise. Our work is not complete, and we will continue to fight for lower health care costs for all Americans.”

Please find soundbites from HHS’ Chief Competition Officer, Stacy Sanders, here .

Because of President Biden’s lower cost prescription drug law, the Inflation Reduction Act, which established the Medicare Prescription Drug Inflation Rebate Program, some people with Medicare who use these drugs during this time period may save between $1 and $4,593 per day.

“Everyone should be able to afford their medication, and the Inflation Reduction Act continues to deliver on this goal to improve affordability,” said CMS Administrator Chiquita Brooks-LaSure. “Discouraging drug companies from price increases above the rate of inflation is a key part of this effort, and CMS continues to implement the law to bring savings to people with Medicare.”

Padcev, a medication used to treat advanced bladder cancer, is an example of a prescription drug with a price that has increased faster than the rate of inflation every quarter since the Medicare Part B inflation rebate program went into effect, resulting in lowered Part B coinsurances for seniors and others with Medicare. A beneficiary taking Padcev as part of their cancer treatment may have saved as much as $1,181 from April 1, 2023 through March 31, 2024, depending on their coverage and course of treatment. Another example, Crysvita, treats a rare genetic disorder that causes impaired growth, muscle weakness, and bone pain. A beneficiary taking Crysvita may have saved as much as $765 from July 1, 2023 through March 31, 2024 depending on their coverage and course of treatment.

The Medicare Prescription Drug Inflation Rebate Program is just one of the Inflation Reduction Act’s prescription drug provisions aimed at lowering drug costs. In addition to this program, the law expanded eligibility for full benefits under the Low-Income Subsidy program (LIS or “Extra Help”) under Medicare Part D at the beginning of this year. Nearly 300,000 people with low and modest incomes are now benefiting from the program’s expansion. A comprehensive public education campaign is underway to reach the more than three million people who are likely eligible for the program but not yet enrolled.

In addition, as of January 1, 2024, some people enrolled in Medicare Part D who have high drug costs have their annual out-of-pocket costs capped at about $3,500. In 2025, all people with Medicare Part D will benefit from a $2,000 cap on annual out-of-pocket prescription drug costs.

The Inflation Reduction Act requires drug companies to pay rebates to Medicare when prices increase faster than the rate of inflation for certain drugs. CMS intends to begin invoicing prescription drug companies for rebates owed to Medicare no later than fall 2025. The rebate amounts paid by drug companies will be deposited in the Federal Supplementary Medical Insurance Trust Fund, which will help ensure the long-term sustainability of the Medicare program for future generations.

For more information on the Medicare Prescription Drug Inflation Rebate Program visit, https://www.cms.gov/inflation-reduction-act-and-medicare/inflation-rebates-medicare

To view the fact sheet on the 64 Part B drugs with a coinsurance reduction for the quarter July 1, 2024 – September 30, 2024, visit, https://www.cms.gov/files/document/reduced-coinsurance-certain-part-b-rebatable-drugs-july-1-september-30-2024.pdf

More information and helpful resources about the Inflation Reduction Act and how it is helping to lower costs for people with Medicare can be found at LowerDrugCosts.gov .

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The Unique Burial of a Child of Early Scythian Time at the Cemetery of Saryg-Bulun (Tuva)

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Pages: 379-406

In 1988, the Tuvan Archaeological Expedition (led by M. E.вЂЇKilunovskaya and V. A.вЂЇSemenov) discovered a unique burial of the early Iron Age at Saryg-Bulun in Central Tuva. There are two burial mounds of the Aldy-Bel culture dated by 7th century BC. Within the barrows, which adjoined one another, forming a figure-of-eight, there were discovered 7 burials, from which a representative collection of artifacts was recovered. Burial 5 was the most unique, it was found in a coffin made of a larch trunk, with a tightly closed lid. Due to the preservative properties of larch and lack of air access, the coffin contained a well-preserved mummy of a child with an accompanying set of grave goods. The interred individual retained the skin on his face and had a leather headdress painted with red pigment and a coat, sewn from jerboa fur. The coat was belted with a leather belt with bronze ornaments and buckles. Besides that, a leather quiver with arrows with the shafts decorated with painted ornaments, fully preserved battle pick and a bow were buried in the coffin. Unexpectedly, the full-genomic analysis, showed that the individual was female. This fact opens a new aspect in the study of the social history of the Scythian society and perhaps brings us back to the myth of the Amazons, discussed by Herodotus. Of course, this discovery is unique in its preservation for the Scythian culture of Tuva and requires careful study and conservation.

Keywords: Tuva, Early Iron Age, early Scythian period, Aldy-Bel culture, barrow, burial in the coffin, mummy, full genome sequencing, aDNA

Information about authors: Marina Kilunovskaya (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Vladimir Semenov (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Varvara Busova (Moscow, Russian Federation). (Saint Petersburg, Russian Federation). Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Kharis Mustafin (Moscow, Russian Federation). Candidate of Technical Sciences. Moscow Institute of Physics and Technology. Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail: [email protected] Irina Alborova (Moscow, Russian Federation). Candidate of Biological Sciences. Moscow Institute of Physics and Technology. Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail: [email protected] Alina Matzvai (Moscow, Russian Federation). Moscow Institute of Physics and Technology. Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail: [email protected]

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Essential Cases in the Development of Public Health Ethics
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This Open Access book highlights the ethical issues and dilemmas that arise in the practice of public health. It is also a tool to support instruction, debate, and dialogue regarding public health ethics. Although the practice of public health has always included consideration of ethical issues, the field of public health ethics as a discipline is a relatively new and emerging area. There are ...
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Angus Dawson, Carla Saenz, Andreas Reis, Gail Bolan. This book is open access, which means that you have free and unlimited access. Highlights ethical issues and dilemmas that arise in the practice of public health. Is a tool to support instruction, debate, and dialogue regarding public health ethics. Increases awareness and understanding of ...
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