🧑‍⚕️Public Health Social Sciences Unit 14 – Ethics & Social Justice in Public Health

Key Concepts in Ethics & Social Justice

• Ethics involves the moral principles that govern a person's behavior or the conducting of an activity and helps determine what is right and wrong
• Social justice focuses on the fair distribution of resources, opportunities, and privileges within a society and aims to address inequalities and promote equity
• Distributive justice ensures the fair allocation of benefits and burdens across a population (healthcare resources)
• Procedural justice emphasizes fair processes and procedures in decision-making and resource allocation
• Respect for autonomy acknowledges an individual's right to make informed decisions about their own health and well-being
• Beneficence requires acting in ways that promote the well-being and best interests of others
  • Includes maximizing benefits and minimizing harm
• Non-maleficence involves avoiding actions that cause harm to others
• Justice as fairness, developed by John Rawls, suggests that a fair society is one in which everyone has equal rights and opportunities

Historical Context of Public Health Ethics

• Public health ethics has roots in the 19th century, with the rise of sanitation and hygiene movements aimed at improving population health
• The Nuremberg Code, established in 1947, set ethical standards for human subjects research following the atrocities of Nazi medical experiments during World War II
• The Belmont Report, published in 1979, identified key ethical principles for research involving human subjects (respect for persons, beneficence, and justice)
• The Tuskegee Syphilis Study, conducted between 1932 and 1972, highlighted the need for informed consent and protection of vulnerable populations in research
  • African American men were denied treatment for syphilis and not informed of their diagnosis, leading to significant harm and mistrust in medical research
• The HIV/AIDS epidemic in the 1980s and 1990s raised ethical questions about stigma, discrimination, and access to healthcare for marginalized communities
• The 2003 SARS outbreak and the 2014-2016 Ebola epidemic underscored the importance of balancing individual rights with public health measures during global health emergencies

Ethical Frameworks in Public Health

• Utilitarianism focuses on maximizing overall welfare or well-being for the greatest number of people
  • Decisions are based on their consequences and the net balance of benefits over harms
• Deontology emphasizes the inherent rightness or wrongness of actions, regardless of their consequences
  • Respect for individual rights and duties is central to this approach
• Principalism, developed by Beauchamp and Childress, identifies four key principles: respect for autonomy, beneficence, non-maleficence, and justice
• Virtue ethics focuses on the moral character of the decision-maker and the cultivation of virtues such as compassion, integrity, and courage
• Care ethics emphasizes the importance of relationships, empathy, and contextual understanding in moral decision-making
• Capability approach, developed by Amartya Sen and Martha Nussbaum, considers the extent to which policies and interventions enhance individuals' capabilities to lead fulfilling lives
• Solidarity requires recognizing our shared humanity and interdependence, and working together to address common challenges and promote the common good

Social Determinants of Health

• Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age that shape health outcomes
• Economic stability, including employment, income, and access to affordable housing and food, significantly impacts health
  • Poverty is associated with higher rates of chronic diseases, mental health issues, and mortality
• Education access and quality influence health literacy, health behaviors, and employment opportunities
• Social and community context, including social support networks, community engagement, and exposure to discrimination and violence, affect mental and physical health
• Health and healthcare access, including insurance coverage, proximity to healthcare facilities, and quality of care, contribute to health disparities
• Neighborhood and built environment factors such as air and water quality, access to green spaces, and transportation infrastructure impact health outcomes
  • Exposure to environmental toxins and lack of access to healthy food options (food deserts) disproportionately affect low-income and minority communities
• Addressing SDOH requires multi-sectoral collaboration and policies that promote health equity and social justice

Health Disparities and Inequities

• Health disparities are differences in health outcomes and opportunities across populations, often linked to social, economic, and environmental disadvantages
• Health inequities are avoidable, unjust, and systematic differences in health that arise from inequalities in social determinants of health
• Racial and ethnic minorities experience higher rates of chronic diseases, infant mortality, and premature death compared to non-Hispanic whites
  • Structural racism, discrimination, and historical trauma contribute to these disparities
• Socioeconomic status (SES) is a strong predictor of health outcomes, with lower SES associated with poorer health and shorter life expectancy
• Rural populations face unique health challenges, including limited access to healthcare services, higher rates of chronic diseases, and increased risk of occupational injuries
• LGBTQ+ individuals experience higher rates of mental health issues, substance abuse, and certain cancers due to stigma, discrimination, and barriers to healthcare access
• Individuals with disabilities encounter physical, attitudinal, and systemic barriers that impact their health and well-being
• Addressing health disparities and inequities requires targeted interventions, community engagement, and policies that promote health equity and social inclusion

Ethical Decision-Making in Public Health Practice

• Ethical decision-making in public health involves balancing individual rights and autonomy with the collective good and population health
• Evidence-based practice requires using the best available scientific evidence to inform public health policies and interventions while considering ethical implications
• Community engagement and participatory approaches ensure that affected communities have a voice in decision-making processes and that interventions are culturally appropriate and responsive to local needs
• Transparency and accountability in decision-making processes build public trust and support for public health measures
  • Clearly communicating the rationale behind decisions and engaging in ongoing dialogue with stakeholders is essential
• Proportionality requires that public health interventions are proportional to the level of risk and are the least restrictive means necessary to achieve public health goals
• Reciprocity involves providing support and resources to individuals and communities who bear disproportionate burdens or face hardships as a result of public health measures
• Solidarity and social cohesion should be promoted through public health interventions that foster a sense of shared responsibility and mutual support
• Ongoing monitoring and evaluation of public health interventions are necessary to assess their effectiveness, identify unintended consequences, and make adjustments as needed

Case Studies in Public Health Ethics

• The New York City Board of Health's decision to ban the sale of large sugary drinks in 2012 raised questions about paternalism, individual choice, and the role of government in promoting healthy behaviors
• The 2014-2016 Ebola epidemic in West Africa highlighted ethical challenges related to quarantine, isolation, and the allocation of scarce resources during public health emergencies
  • Healthcare workers faced difficult decisions about providing care while minimizing personal risk
• The Flint, Michigan water crisis, which began in 2014, underscored issues of environmental justice, government accountability, and the disproportionate impact of public health failures on marginalized communities
• Mandatory vaccination policies, such as those implemented during measles outbreaks, raise questions about balancing individual liberty with the protection of public health
  • Exemptions for personal or religious beliefs can compromise herd immunity and put vulnerable populations at risk
• The opioid epidemic in the United States has prompted debates about harm reduction strategies (needle exchange programs), access to addiction treatment, and the criminalization of substance use disorders
• The COVID-19 pandemic has raised numerous ethical challenges, including the allocation of scarce resources (ventilators, vaccines), the balance between public health measures and individual freedoms, and the exacerbation of existing health disparities
  • Ensuring equitable access to testing, treatment, and vaccines has been a key ethical concern

Future Challenges and Emerging Ethical Issues

• Climate change and environmental degradation pose significant threats to public health, disproportionately affecting vulnerable populations and raising questions of intergenerational justice
• Advances in genetic testing and precision medicine present opportunities for personalized healthcare but also raise concerns about genetic discrimination, privacy, and equitable access
• The increasing use of artificial intelligence and big data in public health decision-making requires careful consideration of algorithmic bias, transparency, and accountability
• The rise of vaccine hesitancy and the spread of misinformation through social media pose challenges for maintaining public trust and achieving high vaccination rates
• Addressing the mental health crisis, particularly among youth and marginalized communities, will require innovative approaches and the allocation of adequate resources
• Preparing for and responding to future pandemics and public health emergencies will necessitate learning from past experiences, strengthening global cooperation, and addressing underlying health inequities
• Promoting health equity and social justice in an increasingly globalized and interconnected world will require addressing the root causes of health disparities and fostering cross-sectoral collaboration
• Balancing individual privacy rights with the use of public health surveillance and data collection methods will become increasingly important in the digital age