Ethical Issues in Public Health Practice in Michigan Sarah E. Gollust, Nancy M. Baum, MHS, Susan D....
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Transcript of Ethical Issues in Public Health Practice in Michigan Sarah E. Gollust, Nancy M. Baum, MHS, Susan D....
Ethical Issues in Public Health Practice in Michigan
Sarah E. Gollust, Nancy M. Baum, MHS, Susan D. Goold, MD, MHSA, MA, and Peter D. Jacobson, JD, MPH
Public Health Systems Research Interest Group
Annual Meeting
June 7, 2008
Background
Academic distinction made between bioethics and public health ethics
Limited empirical evidence on the extent to which public health practitioners experience ethical challenges in daily work
Project Goals
Build empirical base for public health ethics
Identify ethical issues practitioners experience in their daily work
Gain understanding of methods of resolution
Methods
Site selection: 13 local health departments (LHDs) selected for variation in:
Geographic location Population characteristics Governance structure
Recruitment: snowball sampling, starting with health officers at each LHD
Source: Michigan’s Guide to Public Health for Local Governing Entities, November 2006, MALPH
Characteristics of Participating Agencies
Site N per site
County or District
Setting
LHD 1 3 County Urban
LHD 2 3 District Rural
LHD 3 3 County Rural
LHD 4 4 County Urban
LHD 5 5 County Urban
LHD 6 4 County Urban
LHD 7 4 County Rural
LHD 8 3 District Rural
LHD 9 4 County Rural
LHD 10 4 County Rural/Urban
MDCH 6 State N/A
+ 1 City Department Employee and 1 County Commissioner (neither affiliated with sites above)
Occupations of Study Participants
Occupation n
Health Officers 10
Medical/Dental Directors (non-HO) 4
Environmental Health 6
Nursing or Clinic Staff 8
Health Educator 2
Emergency Preparedness 1
Communications/Public Relations 2
Other (LHD employees) 4
County Commissioner/ BOH Member 2
State Employee 6
Total 45
Methods, cont.
Semi-structured, mostly face-to-face interviews with 45 practitioners to identify: Ethical issues faced in practice Underlying values Processes for resolution Demographics and personal exposure to ethics
Qualitative coding and analysis of transcripts
Results
Ease Discussing Ethics
Few practitioners rely on ethical constructs or use the “language” of ethics
No difficulty identifying or discussing ethical issues
Ethical Challenges - 5 Major Themes
1) Appropriate use of public health authorityBalancing public health benefits with individuals’ autonomy or businesses’ economic viability
2) Decisions related to resource allocationChoosing among populations/programs
Allocating scarce resources
Allocating practitioners’ time
5 Major Themes, cont.
3) Political interference in practicePolitics dictates programming, not evidence
Focus on political “issues of the day” rather than community needs
4) Assuring standards of quality care Across different populations
During emergencies
5 Major Themes, cont.
5) Questioning the role or scope of public health
Traditional protection from infectious disease
vs. Safety net
vs. Inclusion of social determinants of health
Public Context
Professional ethics Personnel issues, managing employees Public sector duties Relationships with private sector Conflicts of interest
Public Health Values
Diversity of values, no clear hierarchy or focus across participants Helping the most vulnerable Using public funds efficiently Being consistent Being data-driven Being fair Greatest good for the greatest numbers of people Personal responsibility
Resources Used to Resolve Ethical Challenges
Consultation with colleagues Reliance on personal experience Reliance on personal moral grounding Almost no use of formal frameworks
Discussion
Discussion
Practitioners recognize that their work demands nuanced, ethically-laden decisions
Sense of “doing the right thing” animates practitioners’ daily practice
Discussion
Few differences in major types of ethical issues across practitioners and departments
Practitioners use little formal assistance to process and resolve ethical issues
Creating effective frameworks to assist practitioners will be a challenge
Contribution to Public Health Systems Research
Qualitative research informs the interactive effects of policy and the organizational environment on practice
Identifies how systems-level factors (e.g., funding restrictions) affect practitioners’ daily work
Contribution to Public Health Systems Research
Recognizes that ethical decision-making is an integral part of delivering public health services E.g., decisions allocating resources
May suggest ways to design a system that facilitates ethical decision-making and reduces ethical conflict
Acknowledgements
Greenwall Foundation
Robert M. Pestronk (study consultant)
45 public health professionals for offering us their considerable insights
More information
My email: [email protected] Study publications:
Baum et al. Looking Ahead: Addressing Ethical Challenges in Public Health Practice. Journal of Law, Medicine, and Ethics. 2007; 35(4): 657-667.
Gollust et al. Politics and Public Health Practice: Left and Right Meets Wrong and Right. Journal of Public Health Management and Practice. 2008; Forthcoming.