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Ethics in Public Health
Leila Afshar
MD. PhD of Medical Ethics
Department of Medical Ethics
Shahid Beheshti University of Medical Sciences
Introduction
Ethics v. Morality
Ethics as a normative institution.
Other normative institutions
Ethics
The word ‘ethics’ means the philosophical
study of the moral values of human
contact and the rules and principles that
ought to govern it.
The Levels of Moral Discourse
Meta-ethics
Normative Ethics
Rules and Rights (Code of ethics)
Cases (Casuistry)
Meta- Ethics
1. What is the source of ethics?
 Religious answers:
The divine will
The divine law
 Secular answers:
a. Universal sources(universalists): natural law, actual or
hypothetical contract
b. Relativist answers: one’s culture, one’s personal
preferences, actual social contract
2. How do we know what is ethical?
 Religious answers:
Revelation
Scriptures
Tradition(religious authorities)
Experience and reason
 Secular answers:
• Reason (Kant)
• Experience and observation(Hume: experience of
sympathy)
• Intuition
• Social agreement or contract
Normative Ethics
At this level the broad, basic norms of behavior
and character are discussed.
The key feature of these norms is that they are
general.
They apply to a wide range of conduct and
character.
Moral Agent
Consequences
Action
Three questions of Normative Ethics
Action Theory: what principles make actions
morally right?
Value Theory: what kind of consequences are
good or valuable?
Virtue Theory: what kind of character traits are
morally praiseworthy?
Action theory
What principles make actions morally right?
The answer involves some list of moral
principles such as:
beneficence,
non-maleficence,
respect for autonomy
justice.
will have to address the question of how to
resolve the conflicts that arise among principles.
Value Theory
What kind of consequences are good or
valuable?
The real question here is what kind of things are
intrinsically valuable?
Among the standard answers are happiness,
beauty, knowledge, and importantly for
biomedical ethics- health.
Virtue Theory
What kind of character traits are morally
praiseworthy?
Virtues be understood as referring not to the
actions, but to the people who engage in the
actions.
Benevolence vs. beneficence.
Rules and Rights
Code of Ethics
Often rules and rights express the same moral
duty from two different prospective.
Rules are expressed from the prospective of the
one who has a duty to act; rights claims from
the vantage point of the one acted upon.
How rigidity do rules apply?
 Legalism: there are no exception to the rules and rights.
 Rules of practice: rules specify practices that are
morally obligatory. Exceptions are made only in very
extraordinary circumstances.
 Situationalism: moral rules are merely “guidelines” or
“rules of thumb” that must be evaluated in each
situation.
 Antinomianism: every case is so unique that no rules or
rights can ever be relevant in deciding what one ought
to do in a specific situation.
The Level of the Case
Discussion begins with a case.
Approaches:
Casuistry or paradigm cases: similar cases should be
treated similarly. Or if the relevant features are
similar, then cases should be treated alike.
Agree on what should be done in paradigm case and
agree that the new case is similar in all relevant
aspects.
A Full Theory of Bioethics
 For the last decades of twentieth century, theorists
defending the top-down approach and clinicians the
bottom-up.
 More and more there is agreement that, what is critical
is that, for a full and consistent approach to bioethics,
eventually all four of these levels must be brought into
“equilibrium”.
 It seems less and less important where one starts. One
will move up and down the ladder of the levels of moral
discourse. A stable equilibrium is necessary for a full
and consistent position in bioethics.
Ethical Case Analysis in Public Health
1.
Screening:
a. HIV
b. Genetic
2.
Population Control
Screening
Voluntary
Compulsory
Universal
1
2
Selective
3
4
Case of HIV
1)
2)
Universal & Voluntary: Encouragement and choice
Universal & Compulsory: Coercion

Neither voluntary nor compulsory-universal screening is
justified by current evidence.
HIV infection is not widespread outside groups engaging in
high-risk activities.
Screening in groups or areas with low prevalence produces falsepositive.
Universal screening is very costly and cost-ineffective.
Must be repeated often.




3) Voluntary- selective screening
 In people with unsafe sexual practices
 Share needles in intravenous drug abusers
 Pregnant woman and newborns
Unsolved questions:
Who should be encouraged?
Who should bear the cost?
Pre- and post test counseling.
4) Compulsory-selective screening
It can be justifiable whenever persons engage in
actions or involved in procedures that impose
risks on other who can not avoid those risks.
Blood donation, sperm donation, organ donation
Workplace?
Prisons?
Pregnant women
Genetic Screening
‫طرح کشوری غربالگری سندرم‬
‫داون‬
‫‪ ‬ارجاع تمام خانم های بارداربه مراکز معرفی شده توسط وزارت‬
‫بهداشت‬
‫‪ ‬غربالگری در سه ماهه اول ودوم‬
‫‪ ‬بررسی سونوگرافیک جنین‬
‫‪ ‬بررسی بیوشیمیایی خون مادر( مارکرهای چند گانه)‬
‫‪ ‬محاسبه خطرسندروم داون‬
‫‪ ‬معرفی به مراکز ژنتیک جهت آمنیوسنتزوتایید تشخیص‬
‫‪ ‬معرفی موارد قطعی به مراکز قانونی جهت سقط درمانی‬
‫‪ ‬پرداخت هزینه توسط خانم های باردار‬
‫‪ ‬تقبل نکردن هزینه های غربالگری توسط بیمه ها‪.‬‬
‫انجام ارزیابی ها از چه میزان اهمیتی برخوردار است‪ .‬به‬
‫عبارت دیگر اگر برای انجام دادن یا ندادن آزمایش ها طرف‬
‫مشاوره قرار گرفتیم چه پاسخی بدهیم؟ ارزیابی فایده و خطر ‪.‬‬
‫‪ .1‬آیا رضایت فرد برای انجام آزمایش آگاهانه و آزادانه‬
‫خواهد بود؟‬
‫‪ .2‬آیا صرف منابع نظام سالمت عادالنه هزینه خواهند شد؟‬
‫‪ .3‬آیا اطالعات بدست آمده در دایره رازداری و حریم‬
‫خصوصی افراد قرار خواهند گرفت؟‬
In advising patients about genomic testing be
aware of :
1.
2.
3.
4.
5.
the clinical limitations of testing,
the risk of discrimination,
the importance of informed consent,
the importance of confidentiality, and
the implications for relatives.
The Ethics of Population Control
Reproductive Rights
Contraception
Reproductive rights also means access to Assisted
Reproductive Technologies (ART).
Contraception
The Malthusian Warning (1798) – die-back
Paul Ehrlich (1960) - the resolute practice of
population control.
The critic of population control:
 Religious critics
 Feminist critics
 Cornucopian critics
Leveling Off: The Demographic Transition
Incentives and disincentives
1.
2.
3.
What moral limits are there on the use of incentives and
disincentives to manage population size?
Which are preferable?
How strong may they be?
 The case of India 1975-6
 The Nazis used bronze, silver, and gold medals to reinforce large
family size for Aryan (but not Jewish) women: four, six, and eight
children respectively.
 Ceausescu’s Romania used a variety of harsh disincentives and
penalties for abortion or failure to have an adequate number of
children, set at five
 Singapore (1983)
 China’s one-child program
Contraception mandates vs. family size ceilings
 While in practice contraception mandates and family size ceilings
are often intertwined, they are conceptually different.
 Contraception mandates may alter the decisional structure of
childbearing choices, but still recognize individual preferences in
choices about family size; family size limits may impose a ceiling,
but can leave it to the couple to determine how to prevent
childbearing so as to stay within the limit.
 the question is which form of interference is morally more
tolerable?
Targeting
Optimal Population Size:
Fewer with More, or More with Less?
Contraception vs. Planned parenthood
long-acting reversible contraception, or LARC
ARTs
IVF
Egg or Sperm Donation
Embryo Donation
Surrogacy
‫از میان روش های کمک باروری ذکر شده کدام یک را از نظر اخالقی قابل قبول تر‬
‫می دانید؟‬
‫چالش اخالقی اضافی که هر روش به بار می آورد چیست و چه کس یا کسانی از‬
‫تبعات این اقدام تاثیر می پذیرند؟ ( کودک‪ ،‬مادر‪ ،‬اهدا کننده‪ ،‬پدر‪ ،‬خانواده و یا جامعه)‬
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