Ethical Considerations in Public Health Practice:

Addressing Challenges and Embracing

Opportunities
Abhay Gaidhane (  abhaygaidhane@gmail.com )
JNMC, Datta Meghe Institute of Higher Education and Research
Sonali Choudhari
JNMC, Datta Meghe Institute of Higher Education and Research
Shilpa Gaidhane
JNMC, Datta Meghe Institute of Higher Education and Research
Mahalaqua Nazli Khatib
JNMC, Datta Meghe Institute of Higher Education and Research
Quazi Syed Zahiruddin
JNMC, Datta Meghe Institute of Higher Education and Research

Research Article

Keywords: Public health programs, Autonomy, Justice, Ethics, Review, Framework

Posted Date: August 22nd, 2023

DOI: https://doi.org/10.21203/rs.3.rs-3259889/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.
Read Full License

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Abstract
Public health is a government responsibility to ensure the health and well-being of community.
Implementing public health functions like surveillance and contact tracing can raise ethical concerns
about individual rights and autonomy. This paper discusses public health professionals' ethical
challenges and explores potential solutions.

The study utilized interviews, focus group discussions, and published literature that presented various
ethical frameworks from different sources. These frameworks offer guidance for ethical decision-making
and can assist policymakers and practitioners in navigating complex ethical dilemmas in public health.
Public health programs face ethical challenges concerning stigmatized diseases, resource distribution,
autonomy versus public good, and community involvement. Professionals stress the need for ethical
training to effectively make informed decisions and evaluate policies.

Integrating ethical considerations into public health initiatives can improve healthcare delivery and
community well-being. The framework can aid professionals in evaluating public health programs
ethically, ensuring that public health practices are just and respectful.

INTRODUCTION:
Public health is a crucial field that aims to promote and protect the health of individuals and
communities while fostering overall well-being through organized efforts at various levels – individual,
societal, environmental, and policy (Acheson D 1988; Angus and Marcel 2009). While health involves
individual choices, public health is primarily the government's responsibility at different levels, such as
community, state, and national (Kass 2001; Tulchinsky et al. 2015).

The traditional focus of bioethics has been on individual choices and rights, and therefore the specific
public health functions, like surveillance, notification, and contact tracing, may raise concerns about
potential infringement on individual rights and choices. Public health practice often encounters ethical
dilemmas, particularly when balancing individual autonomy with the government's responsibility to
provide healthcare to the population. Thus, public health programs and research must be guided by
ethical reasoning and involve community engagement at all levels and stages of implementation.
Although various frameworks exist to help public health professionals review their programs from ethical
perspectives, they may need more practical guidance (Kass and Gielen 1998; Kass 2001; Krebs 2008; ten
Have et al. 2010; Tulchinsky et al. 2015).

This paper aims to address the ethical challenges faced by public health professionals and explore
potential opportunities and approaches to overcome these challenges, especially in the context of India
and other low-resource settings. By ensuring ethical considerations are integrated into public health
initiatives, we can better navigate the complexities of healthcare delivery and ultimately improve the well-
being of communities.

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METHODOLOGY:
We conducted a comprehensive study involving ten in-depth interviews with public health professionals
and practitioners at the district and state levels. Additionally, we conducted three Focus Group
Discussions (FGDs) with program implementers at the district and sub-district levels. The aim of these
interviews and FGDs was to delve into the various ethical challenges professionals face while planning
and implementing public health programs and to understand where they seek help when encountering
such challenges.

To gain a broader understanding of ethical frameworks in public health programs and research across
different settings, we conducted a systematic review of relevant literature. Our search strategy included
specific terms and phrases such as "Public Health," "Ethics," "Ethical Declaration," "Ethical Framework,"
"Public Health Research," "Public Health Institutions," and "Ethics in Public Health Education." We also
examined key documents, including the UN Declaration (1942), Helsinki Declaration, and Universal
Declaration on Bioethics and Human Rights (October 2005).

The data from the in-depth interviews and FGDs were meticulously transcribed, and independent
observers analysed the transcripts. We identified key themes related to ethics in public health practice
and research from this analysis. Simultaneously, we extracted data from the systematic literature review
and identified additional key themes relevant to ethics and public health.

We triangulated the findings and key themes from the in-depth interviews, FGDs, and the systematic
literature review to ensure robustness and accuracy. This approach allowed us to gain comprehensive
insights into the ethical challenges faced by public health professionals and practitioners. It contributed
to a more nuanced understanding of ethical considerations in public health programs and research.

RESULT:
Public health practices, such as notification, contact tracing, surveillance, isolation, and quarantine, often
present ethical challenges. The principle of individual autonomy becomes particularly difficult to uphold
while delivering these functions, especially when dealing with stigmatized diseases like tuberculosis, HIV,
sexually transmitted infections, leprosy, and mental health conditions.

Respondents emphasized that ethical challenges in public health management also arise from issues
such as equitable resource distribution, conflicting priorities of government and program implementers,
improving healthcare access for vulnerable and socially disadvantaged populations, and involving
communities in decision-making.

A common theme observed in the in-depth interviews and FGDs was - limited knowledge of ethical
principles and their application in public health practices. FGD participants stressed the need for in-
service training and capacity-building programs on ethical issues in public health practice. They
highlighted the need for equipping public health professionals with skills to make informed decisions by

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weighing the risks versus benefits of public health programs. Respondents also emphasized the critical
appraisal of policies and implementation guidelines from an ethical viewpoint before passing them on to
the district or peripheral level for implementation.

The lack of rigorous scientific scrutiny of public health interventions for ethical issues was attributed to
several factors – lack of awareness and training in bioethics and public health ethics, the absence of
frameworks for ethical review of public health programs in developing countries, and the lack of standing
mechanisms or committees to review public health programs—additionally, a top-to-down approach in
policy and program design and implementation needs for more scrutiny.

Systematic Review of Literature

A total of 86 documents were assessed, and after careful examination, 22 were found to be relevant and
included in the study. These documents encompassed a variety of sources- journal articles, frameworks
for ethical review, reports, book chapters, and declarations. Each of these documents was thoroughly
reviewed to extract pertinent information. While most of these documents served as broad guidelines for
ethical review, they were not intended to be a specific code of conduct or guiding principles for ethics in
public health practice. In the subsequent sections, we present key frameworks and guidelines,
highlighting their salient features that align with the objectives of this paper. These frameworks serve as
valuable resources for ethical considerations in public health practice.

Nancy Kass (2001) proposed a comprehensive Framework of Public Health in the US (Kass 2001),
presenting an analytic tool comprising six essential questions for decision-making concerning the
balance of risks and benefits in public health programs. The author offers a detailed exploration of the
pertinent ethical considerations related to these six issues. This framework is designed to address the
fundamental values of public health, with a particular focus on the government's responsibility to
enhance the community's overall health while also striving to minimize social inequalities. Moreover, the
paper delves into ethical dilemmas concerning the burden on individuals or communities, particularly in
privacy, confidentiality, autonomy, and justice. By presenting this analytical tool, the framework provides a
valuable resource for public health practitioners to navigate the ethical complexities inherent in their
decision-making process. It enables a more robust and thoughtful approach to balancing the welfare of
both individuals and the broader community within public health programs (Kass 2001).

Childress et al. (2002) developed a Framework for Public Health Ethics in the USA to reconcile conflicts
between promoting public health and upholding other moral values. The paper presents a conceptual
framework that addresses nine general moral considerations within the context of public health ethics.
The first three moral values align with the primary goal of public health, emphasizing promoting public
health and well-being. The subsequent values focus on maintaining confidentiality, trust and managing
the balance between them. The framework provides insight into the degree of protectiveness required in
public health interventions and the ethical considerations surrounding coercive interventions in behaviour.
This framework is valuable for public health professionals, helping them navigate complex ethical
dilemmas and make informed decisions that balance promoting public health objectives and respecting
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other moral values. By incorporating these moral considerations into their practices, public health
practitioners can ensure their interventions are ethically sound, transparent, and aligned with the welfare
of individuals and communities (Childress et al. 2002).

The European Framework on Public Policies, Law, and Bioethics (2006) offers valuable guidance for
developing and implementing public health policies and programs throughout the European Union. It
provides a structured approach to analysing the potential conflicts between individualistic perspectives
and the community's interests. The paper comprehensively analyses community attitudes towards
various topics, such as parental rights, incentives and enforcement, solidarity, and individual rights and
responsibilities. The framework aims to balance individual autonomy and promote the community's well-
being by understanding these attitudes. Within this framework, three primary goals are proposed: first, the
promotion of population health; second, the encouragement of health-related autonomy; and third, the
promotion of health-related equality. By incorporating these goals into public health policies and
programs, the European Union can work towards achieving better health outcomes for its citizens while
upholding their rights and respecting their autonomy.

This framework serves as a valuable resource for policymakers and public health professionals across
Europe, offering a systematic approach to address complex ethical considerations and enhance the
effectiveness of public health initiatives. By aligning policies and programs with these goals, the
European Union can advance its public health agenda while ensuring a fair and equitable approach to
healthcare delivery (Shickle et al. 2006).

The Nuffield Council on Bioethics framework (2007) is dedicated to addressing public health ethics
issues for a wide range of stakeholders, including policymakers in government, industry, organizations,
and individuals. Within this framework, two analytic tools are proposed to guide decision-making. The
first tool is the 'stewardship model,' which outlines acceptable goals and restrictions for public health
policy. It emphasizes achieving desired health outcomes while minimizing limitations on people's
freedom. Special attention is given to consent considerations and the care of vulnerable populations. The
second tool is the 'Intervention ladder,' which categorizes public health policies based on their level of
invasiveness on individual choices. This ladder helps indicate the "stronger justification" needed for an
intervention or program as it moves higher, i.e., becoming more intrusive in individuals' choices.

These analytic tools provide guidance to policymakers and stakeholders involved in public health
decision-making. By utilizing these tools, they can carefully balance public health objectives with
individual autonomy, ensuring that interventions and policies are ethically justified and respectful of
people's rights and liberties. The framework provides a comprehensive and structured approach to
address complex ethical considerations and promote responsible and evidence-based public health
policies and programs (Anonymous 2007; Krebs 2008).

In 2008, Tannahill introduced a set of guidelines to aid decision-making regarding implementing

interventions. These guidelines consider the interplay of evidence and ethics in the decision-making

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process. The framework is depicted as a 'decision-making triangle,' wherein ten ethical principles form the
apex, and evidence and theory constitute the base.

The proposed framework offers a structured approach for decision-makers to weigh ethical
considerations alongside empirical evidence and theoretical foundations when determining whether to
implement an intervention. By adopting this framework, decision-makers can enhance accountability,
transparency, and openness in their decision-making processes. It enables a comprehensive and
balanced approach to address potential interventions' ethical implications and evidence-based merits,
ultimately contributing to a more informed and responsible decision-making (Tannahill 2008).

The 'Principles of the Ethical Practice of Public Health' (2002) established by the Public Health
Leadership Society offers a code of ethics for public health institutions, which the American Public Health
Association subsequently adopted. By adhering to these ethical principles, public health institutions can
ensure their practices are guided by community engagement, evidence-based decision-making, and a
commitment to respecting the values and needs of diverse populations. This code of ethics is a valuable
and comprehensive guide for promoting ethical practice within the public health (American Public Health
Association 2002; Demetrius James 2004).

The World Medical Association's Declaration of Helsinki, first introduced in 1964 and amended in 2013,
prioritizes the privacy and autonomy of individuals involved in medical research. It emphasizes the
significance of obtaining informed consent from research participants, ensuring they fully understand the
purpose of the study and its potential benefits. The Declaration underscores the need for research to have
a clear rationale and to employ scientifically sound approaches. It emphasizes that the potential benefits
of interventions should outweigh any potential harm to the participants. The Declaration is also
mentioned about protecting control group participants, ensuring they are not subject to undue risks or
disadvantages. A vital principle of the Declaration is finding a delicate balance between safeguarding the
well-being of individual participants and advancing scientific knowledge and societal benefits. This
principle recognizes that medical research should contribute positively to the individual participant and
the broader society (World Medical Association 2013).

The Universal Declaration on Bioethics and Human Rights, dated 19th October 2005 (Article 27),
emphasizes that applying its principles should be restricted solely to situations governed by law. This
includes laws enacted in the interest of public safety, the protection of public health, or the safeguarding
of the rights and freedoms of others. Importantly, any such law must harmonize with international human
rights law (UNESCO 2005).

In the Universal Declaration of Human Rights (1948), Article 25 asserts that every person has the right to
a standard of living that is essential for their health and well-being and that of their family. This standard
includes access to necessities such as food, clothing, housing, medical care, and essential social
services. Article 30 clarifies that nothing in the declaration can be interpreted as granting any state, group,
or individual the right to engage in activities or actions to undermine the rights and freedoms outlined in

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the declaration. In other words, the declaration does not condone or support actions that seek to destroy
the fundamental rights and freedoms enshrined in it (Anonymous 1948; UNESCO 2005).

The Public Health Accreditation Board's Standards and Measures (version 1.5; Measure 11.1.2 A)
addresses the importance of identifying ethical issues and making ethical decisions within public health.
These measures serve as valuable tools for assessing health policies and their implementation, enabling
identifying and resolving ethical challenges that may arise in public health programs and interventions.
By incorporating these standards, public health practitioners can ensure that their practices align with
ethical principles and promote the well-being and rights of individuals and communities (Anonymous
2013).

In 2016, Barrette et al. presented case studies that offer an ethical viewpoint for public health
practitioners, spanning all levels and functions within the field of public health. These case studies serve
as valuable learning resources, illustrating how to critically analyse public health practices from an
ethical perspective. The case studies highlighted that while clinical and research ethics are essential, they
alone are insufficient for adequately reviewing public health programs or interventions. As a result, the
authors recommended the development of a dedicated framework for the ethical review of public health
programs. This framework should carefully consider both individual autonomy and the interests of the
public as a whole (Drue H. Barrett et al. 2016).

A study conducted by Gopicharan in India highlights the significance of ethical considerations in the
monitoring and evaluation (M&E) of public health programs. The key ethical aspects encompass
avoiding conflicts of interest, upholding independence, ensuring fairness, transparency, privacy, respect,
responsibility, accountability, empowerment, and sustainability. Despite existing ethical frameworks in
public health, none specifically address M&E. The paper proposes a theoretical framework for the ethical
review of M&E proposals, offering guidance to ethics committees in their assessments. Additionally, a
case study is presented for illustration (Gopichandran and Indira Krishna 2013).

DISCUSSION:
Ethical principles are vital in shaping public health programs, guiding practitioners to prioritize
individuals' and communities' well-being. This ensures positive health outcomes and equitable access to
healthcare for vulnerable populations. Programs must balance individual choices with the greater good
by providing essential information (Ronald Bayer et al. 2006). They should safeguard sensitive
information, obtain informed consent, and carefully assess risks and benefits. Ethical principles advocate
evidence-based practices, community engagement, transparency, and accountability in program decision-
making. Overall, ethical principles provide a moral framework that guides the development and
implementation of public health programs, ensuring that they are just, respectful, and effective in
improving population health and well-being.

However, numerous public health programs challenge the fundamental principles of bioethics,
necessitating a unique approach (Angus and Marcel 2009; Kass 2001; Marckmann et al. 2015; Rogers
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2004). Conducting an ethics analysis can shed light on these programs' fairness, respect, and relevance,
enhancing the validity of public health interventions. Our study emphasizes significant concerns arising
from the need for systematic ethical review for public health interventions or programs. Addressing these
ethical challenges in public health practices requires fostering greater awareness, providing appropriate
training to public health professionals, and developing robust ethical frameworks and the lack of
institutional mechanisms to address these issues.

It is crucial to create awareness and enhance the ethical reasoning of public health professionals
regarding public health programs. In-service training can effectively achieve this goal. Training programs
should focus on increasing awareness and improving ethical decision-making skills to address various
ethical conflicts encountered in public health practice. Implementing a case-based approach, where
professionals engage in thought-provoking discussions on routine ethical challenges, can significantly
contribute to capacity building. However, incorporating ethics into public health academic curricula varies
across courses and institutions and needs to be revised (Baum et al. 2009; Pati et al. 2016). Structured
ethics education with dedicated modules and credits should be integral to public health education.

Based on themes from in-depth interviews with public health professionals and a review of guidelines by
other authors, we proposed a framework for the ethical evaluation of public health programs, functions,
interventions, or research. The framework addresses several critical issues, such as assessing the
program's relevance, effectiveness, conducting harm-benefit analysis, exploring alternative approaches to
addressing the public health problem, and considering issues of autonomy, equity, and data.

Table 1 presents the key questions that should be examined when reviewing programs from an ethical
perspective. By systematically addressing these questions, the framework helps ensure that public health
initiatives are ethically sound and aligned with the well-being of individuals and communities.

This framework serves as an analytical tool to guide public health professionals in considering the
ethical implications of their programs, policies, interventions, or functions. It is not meant to be a rigid
code of ethics but rather a flexible guide for ethical decision-making.

The level of ethics review of the public health programs/interventions should be proportionate to the
potential risks or harms to individuals and communities. To ensure effective and fair implementation of
the ethical review process, it is essential to institutionalize the entire review mechanism. This can be
achieved through a government-accredited review board, either standalone or as a subcommittee of an
existing review board, dedicated to evaluating public health programs from an ethical standpoint. Such
institutionalization promotes accountability and transparency in the review process.

Ethical review enhances public health programs' credibility and uptake. It molds programs to fit the
context, increasing community acceptance, inclusivity, and equity. It minimizes risks of marginalization,
aligns with national health goals, guides resource allocation, and reduces restrictions on autonomy. The
involvement of civil society and communities builds trust in the public health system.

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To conclude, public health ethics, like research ethics and good clinical practices, need attention. Public
health impacts large populations, so all programs and policies should undergo comprehensive ethical
review. Public health interventions uphold fairness, respect, and community well-being by integrating
ethical considerations into planning and implementation. The proposed framework ensures that
decisions align with ethical principles, promoting individual and community welfare. Raising awareness
and capacity building of public health professionals around ethical issues will foster an ethical culture.

Declarations
Ethics: The study was approved by the institutional Ethics Committee of Datta Meghe Institute of Medical
Sciences

The consent was obtained from the respondents of the FGD. No other primary data was collected for the
study.

Competing interest: Authors declared no competing interest for the study

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Table 1
Table 1: Ethical Review Framework for Public Health Programs in Indian & LMIC Contexts

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SN Parameter Key questions to consider?
1 Relevance What are the goals of the
proposed public health
program/intervention/research?
2 Effectiveness Are goal and targets of the
proposed public health program
achievable?
How effective is public health
program in achieving its stated
goals?
3 Benefits and What are the expected benefits
potential of program / intervention to the
harm to target population?
population
What are the possible burden or
harm of public health program?
Are the potential benefits of the
action justified?
4 Alternative Can burden be minimized?
approaches
Are there alternative
approaches?
Are there enough justification or
evidence for proposing the
specific public health action?
7 Autonomy How does the intervention affect
the autonomy of the individuals
in target population?
Does the public health action
respect professional and civic
roles and values?
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Explanation
Public health programs or functions
should not operate in isolation but rather
align with the overarching objective of
enhancing core health indicators and
promoting the well-being of the
population. It is crucial to provide
sufficient justification and demonstrate
the significance of any proposed public
health program or research.
Is the program/intervention supported by
evidence relevant to the specific problem
at hand? The evidence provided must be
appropriate for the context in which it will
be implemented. Additionally, are there
any relevant laws and regulations that
need to be considered?
Public health interventions, especially
targeted ones, carry the potential to
segregate community groups and give rise
to stigma and discrimination, affecting
populations like sex workers, injection
drug users (IDUs), leprosy patients, and
those with HIV infections. While targeted
interventions may prove cost-effective, it
is crucial to assess and compare the risks
of stigmatization and discrimination
against the potential benefits before
implementing such interventions.
Thoroughly considering and analyzing
alternative approaches or actions for a
public health problem can lead to
identifying ethically justifiable options.
Advocating for interventions should be
grounded in factual evidence rather than
mere beliefs.
The central question that public health
programs must address is how to
minimize restrictions and intrusiveness
while achieving their objectives. Certain
public health functions, like Notification,
Isolation, and Quarantine, may challenge
individual rights; however, they are
necessary for the greater public good and
should be supported by appropriate laws.
 When deciding to implement such
programs, public health professionals
must carefully weigh the benefits they
offer against the potential risks to
individual autonomy. Finding the right
balance is crucial in ensuring both public
well-being and the protection of individual
rights.

8 Impartiality, Is it possible to fairly implement Ensuring fair distribution of potential

Equity and the public health program? benefits and harms, along with proper
Equality representation of vulnerable communities,
is vital.

Are benefits and risks of a Equitable allocation of resources,

program balanced? regardless of social, ethnic, or regional
differences, is crucial for the optimal
functioning of the public health system.
Evidence-based and data-driven resource
allocation, supported by policies like
conditional cash transfers, can play a
significant role in achieving this goal.

Adapting interventions to reach vulnerable

and underserved populations helps avoid
unnecessary wastage of resources while
ensuring equitable access and distribution
of resources. This approach promotes
fairness and equity in healthcare resource
utilization.

9 Ethics and Are public health data collected Ethical principles play a crucial role in
data ethically? safeguarding confidentiality, security, and
access to patient records within public
Was informed consent was health programs or interventions. To
taken? ensure ethical conduct, these initiatives
must clearly outline the methods and
How the data security and approaches for data collection, handling,
confidentiality issues are storage, and security.
addressed?
In addition to data management, key
issues that must be explicitly addressed in
the public health program proposal or
operational guidelines include
establishing methods or approaches to
ensure community confidentiality,
developing guidelines for data sharing,
determining data ownership, maintaining
data quality, and upholding transparency
in data handling. Adhering to these
principles ensures responsible and ethical
practices in handling sensitive
information within public health
initiatives.

10 Cost invested What is the cost and opportunity Every public health function or
and cost of intervention? intervention carries costs and places a
burden on limited resources. Therefore,
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opportunity the review process must address a critical
cost question: Is the cost of the intervention
justified considering the short- and long-
term benefits for both society and
individuals?

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