Is it ethical to be a 'whistleblower' during COVID-19 pandemic? Ethical challenges confronted by health care workers in China.

The emerging field of public health ethics

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.

Characteristics of deaths amongst health workers in China during the outbreak of COVID-19 infection

LANGUAGE NOTE | Document text in English ; abstract also in Chinese. 本文介紹生物倫理學與公共健康倫理學領域，並描述兩者之間的關係；文章尾聲將展望公共健康倫理學論未來既廣泛又多變的方向。本文首先簡介公共健康倫理學的本質，以及如何把其與比之更廣闊的生物倫理學作出區分，因此需要提出公共健康倫理學的定義，以助釐清公共健康倫理的重點。隨後，本文簡述公共健康倫理學文獻的一些最新進展，包括圍繞新冠病毒、大流行病、抗菌素抗藥性、「生活方式」疾病及正義等道德問題。本文同時論及就干預公共健康的「合法範圍」所提出的觀點之間於政治及形而上學的角力。其後本文探討公共健康倫理學所面臨的挑戰，包括其複雜又多元的性質。而且公共健康實踐高度政治化，其政治化的原因是因為公共健康影響整個人口及社區，而很多關於公共健康的決策由政治人物而非公共健康專家所作出。此外，公共健康倫理也因為公共健康的範圍擴展至納入非政府公共健康行動者而面臨進一步的挑戰。本文最後闡述有關公共健康的一些未來方向，包括「公共健康觀」的出現，以作為為人熟知的健康與社會問題的形而上學框架、把該領域的認知和道德基礎去殖民化以涵蓋更廣泛的知識，以及一些包括美德在内的公共健康倫理學的理論發展。筆者建議讀者把文章視為對公共健康倫理學領域的一部分介紹，並鼓勵他們閲讀本文所引用的論文，並以這些論文作為進入所涵蓋主題的大量文獻之門徑。公共健康倫理學是一個相對年輕的領域，而該領域有著巨大的成長及發掘更多新概念的潛力。 This essay begins by introducing the fields of bioethics and public health ethics and describing the relationship between them. It ends with some glimpses into the wide-ranging and discourse-changing directions of the literature on public health ethics. To open, the paper describes the field of public health ethics and how it is differentiated from the wider field of bioethics. This requires a brief description of public health to clarify the nature of public health ethics. The essay then provides a brief overview of a few recent developments in the public health ethics literature, including the moral issues raised by COVID-19 and pandemics, anti-microbial resistance, ‘lifestyle’ diseases and justice. The paper also touches on the political and metaphysical tensions in views on what counts as a ‘legitimate area’ of intervention for public health. The essay then turns to a couple of challenges in the field of public health ethics, specifically the complex and multi-disciplinary nature of the field and the fact that public health practice is a highly political area. Public health is political both in the sense that it affects entire populations or communities and in the sense that many decisions about public health are made by politicians rather than public health experts. A further challenge to public health ethics is the question of what counts as ‘public health’, as the scope has been broadened to include non-governmental public health actors. Finally, the essay describes some future directions for research in public health ethics, including ‘public health view’ becoming a metaphysical framing for familiar health and social issues and decolonising the epistemic and moral foundations of the field to include a wider set of knowledge sources and values. There are also some theoretical developments that integrate virtue into public health ethics. The reader should take this essay as a partial introduction to the field, and they are highly encouraged to read the papers that are cited here and to use those papers as a gateway into the large literature on the topics covered. Public health ethics is a relatively young field, with an enormous potential for growth and new ideas.

"This article asks the difficult questions- what is public health? and what is public health ethics? The article also recognizes that even though public health and biomedical ethics overlap, they have distinct aspects. The article examines the unique population-based perspective of public health and how it can be distinguished from patientcentered biomedical ethics. Additionally, public health scholars and practitioners often use ethical analyses with other forms of reasoning, particularly law and human rights. The article, therefore, explores the relationship among public health ethics, public health law and human rights. The various meanings of each form of reasoning are discussed, as well as the similarities and differences among them. The article concludes with a proposal for reconciling the inherent tradeoffs between public health and civil liberties. Prior to exercising compulsory powers, public health officials should examine the risk to the public; the likelihood that the intervention will be effective; the opportunity costs; the burdens on human rights and the policy`s fairness."

Aristotle In this issue of Public Health Reviews, we turn our attention again to public health ethics. In our 2012 issue dedicated to this topic, we published 17 papers on a variety of aspects of ethical public health practice. In that issue, Aceijas et al. surveyed European schools of public health and reported that of the 40 schools responding, a large majority stated that they included ethics in their academic programs [1]. However, the content and nature of teaching was variable and often taught in an unsystematic way. These results are similar to other studies conducted in the United Kingdom [2] and the United States [3]. European schools of public health expressed interest in improving the teaching of public health ethics and asked the Association of Schools of Public Health in the European Region (ASPHER) for support.In response to this request, the editors of Public Health Reviews gathered papers that focus on teaching public health ethics. In the introductory piece, Towards Public Health Ethics, Royo-Bordonada and Roman-Maestre report on the relationship between practice and ethics, examining the raison d'etre of ethics and providing a justification for the need for ethics in public health practice. This and the other papers included in this issue-developed in collaboration with the ASPHER Working Group on Ethics and Values in Public Health-examine various topics including what we should teach, how we should teach it.An important related question is why we should teach public health ethics. Fundamentally, we must teach public health ethics because ethical practice creates and maintains public trust and public health cannot function without public trust. To serve the public-whether through controlling an outbreak of an infectious disease, preparing for or responding to public health emergencies, or reducing the impact of non-communicable diseases-communities and individuals must trust our decisions and actions. This trust grows in large part from past successes, transparent and participatory decision making, and ethical management of the inevitable moral tensions that arise in our work.There is certainly no reason to believe that public health practitioners start from an unethical or immoral stance; quite the contrary, in fact, the vast majority of public health professionals are drawn to the field because of its noble mission. This mission includes a bent toward social justice, mitigating health disparities, and consideration of the community perspective. Solving challenging public health problems, however, requires more than a moral stance [4]. It often requires choosing between two undesirable actions or reconciling tension between competing reasonable interests. These types of ethical decision points are not exceptional; public health practitioners report facing such tensions and challenges in their daily work [5, 6]. Given the numerous and diverse stakeholders affected by public health interventions and the complex systems in which we work, public health professionals must have skills to negotiate solutions that meet diverse, and often conflicting needs. We must prepare public health professionals to move beyond a naive approach of responding to ethical tensions according to their personal moral compass and equip them with skills to recognize ethical dimensions of their work, articulate them, consider possible paths forward, and implement decisions based on both scientific and ethical grounds [4].We must, however, consider past ethical failures and abuses with which public health officials were directly or indirectly involved. While we believe that most public health professionals feel a calling to the mission of public health, the history of the field contains a number of serious ethical lapses. Some of these abuses were located in a particular institution or region and involved wrongful medical interventions-such as eugenics using sterilization and killing for racial purification-purportedly justified by a larger public health objective [7-9]. …

The Ethics of Public Health

Global pandemic perspectives: public health, mental health, and lessons for the future

PC-FACS: COVID-19

Jaffe and Hope provide an insightful analysis of the ethics implicit in public health interventions. According to them, public health interventions are traditionally divided into two categories: (i) interventions that are beneficial to the recipients [and wider society] (for example, vaccinations); and (ii) interventions that are required to prevent such serious harm to the general population that coercive measures by the state is justified and regulated through public health law (for example, isolation and quarantine). Using the proposed provision of anti-retroviral treatment to all HIV-infected individuals, regardless of the degree of their immune suppression, as proposed by Granich et al. (2009), as an example, Jaffe and Hope argue that such a measure constitutes a third category of public health interventions (hereinafter referred to as ‘category 3′ public health interventions) as they are neither unequivocally in the best interests of the recipients nor given within a clear legal framework designed for imposing restrictions on individuals who are a danger to public health. In addressing the issue of whether there are any widely accepted ethical models within medicine that allow some people to be given an intervention that, on balance, risks more harm than good for the sake of benefit to others (i.e., category 3 measures), Jaffe and Hope argue that ‘the ethical framework and standards that have been, and continue to be, developed in the context of medical research provide a useful model for public health’, and base their proposed ethical framework, thereon. In their view, category 3 public health interventions can ethically proceed if they meet six “necessary conditions”. While Jaffe and Hope’s proposed framework is a welcome addition to the relatively nascent field of public health ethics, it is not clear why they omitted alluding to, and appraising the appropriateness of, pioneering public health ethics frameworks, such as those proposed in the last decade by Kass (2001), Childress et al (2002), Upshur (2002), and Gostin (2003), in relation to category 3 public health interventions / measures. Although they cite Gostin’s 2002 seminal work on public health law, their inexplicable omission to discuss existing public health ethics frameworks gives the impression that Jaffe and Hope are either unaware of the existence of such proposed frameworks (which seems unlikely), or that they believe that such frameworks are inappropriate evaluative models for category 3 public health measures. The latter would be puzzling given the apparent similarities between all the proposed frameworks, to date, theirs included. If they believe the latter is applicable, the onus was/is on Jaffe and Hope to adduce relevant arguments to justify why this is so. Otherwise they risk seemingly reinventing the wheel. While there are distinct differences between Jaffe and Hope’s framework and those that preceded it (for example, none of the earlier public health ethics frameworks regards an informed consent process as a necessary condition to implementing a public health measure), there are striking similarities too. For example, Jaffe and Hope’s third necessary condition (the public health benefit cannot be produced by an alternative means that is ethically preferable) is akin to Childress et al.’s Least Infringement principle, Kass’ Burden Minimisation / Alternative Approaches principle, and Upshur’s Least Restrictive or Coercive Means principle. Similarly, Jaffe and Hope’s fourth proposed necessary condition (the public health benefit is such as to justify the risk of harm to participants) is akin to Childress et al’s Necessity principle, Kass and Gostin’s respective Effectiveness principles, and Upshur’s Harm principle. Likewise, Jaffe and Hope’s sixth necessary condition (the public health measure is scrutinized by some properly constituted and appropriate independent body) is akin to Childress et al’s Public Justification principle, Kass’ notion of procedural justice outlined in her principle of fair balancing of burdens and benefits, and similar in sentiment to Upshur’s Transparency principle (although all three latter frameworks also differ in that they do not make reference to Norm Daniel’s Accountability for Reasonableness model). Given these overall similarities, it is not clear if / how Jaffe and Hope’s proposed “necessary conditions” differ, or are meant to differ, from the proposed “principles” enunciated in proposed frameworks of Kass, Childress et al, Upshur, and Gostin. Arguing that there is a distinction between a “necessary condition” and a “principle” is unsustainable as the latter could easily be phrased as a “necessary condition”. For example, Upshur’s proposed public health ethics framework posits the principle of Reciprocity (which has no parallel in Jaffe and Hope’s model, although it would be very useful if incorporated). Rebranded as a “necessary condition” could see the principle of Reciprocity phrased as follows: “Those affected by a proposed intervention/measure should be adequately compensated and/or offered viable alternative interventions of equal or superior efficacy, if such alternate interventions exist”. Using Granich et al’s HIV treatment proposal as an example, the principle of Reciprocity would require public health authorities to prospectively put in place mechanisms that ensure that recipients who have adverse reaction to first-line ARVS are immediately switched to second-line therapies, at state expense. Furthermore, those who experience severe adverse reactions as a result of their treatment regimen must be fairly compensated. While Jaffe and Hope’s proposed framework is a valuable addition to current literature on public health ethics, it would be helpful to see a follow-up manuscript from them wherein they reconcile or distinguish their proposed public health ethics framework with/from those that have preceded it. This will strengthen not just their proposed framework, but also the field of public health ethics.

Foundation and Continuation of Public Health ReviewsPublic Health Reviews (PHR) was founded in 1972 in Israel and published for over 30 years, with listing in Pubmed, Medline and Index Medicus and many other on-line data bases until the owner retired. The journal was purchased in 2010 by the EHESP (Ecole des Hautes Etudes en Sante Publique, the French National School of public health) and established with a distinguished international Editorial Board.The mission of PHR since 2010 has been to provide access to European and global public health students, teachers, researchers, practitioners and policy makers of theme topic reviews of high quality to promote learning and discussion of issues in public health from a multi disciplinary point of view. The Editorial Board participated actively in policy development and leadership of many of the theme issues that evolved. PHR strives to bring topical reviews to promote translation of evidence and science into applied public health policy and practice, including the evolution of health systems as part of public health spectrum [1].The theme topics PHR issues during 2010-2013 included:*The New Public Health*Ageing Societies*Public Health Education*Cardiovascular Disease*Ethics in Public Health*Mental Health as a Public Health Issue*Towards a Healthier 2020, and*Substance Use Issues: New Insights.The New Home for Public Health Reviews 2014In 2014, a further reformation of PHR was arranged with affiliation and sponsorship by the Association of Schools of Public Health in the European Region (ASPHER), along with continued sponsorship by EHESP, and an additional sponsor, a Swiss School of public health. An agreement was signed with Biomed Central to publish PHR as an online open access journal. The new arrangements for sponsorship and operation of PHR provided for the continued mission of each issue addressing concepts such as health disparities, social determinants of health, demographic shifts and changing patterns of health needs, education of the public health workforce and policy makers, and healthcare delivery systems. [1].A new Editorial Board (EB) was organized with a strengthened European, international and multi-disciplinary composition to continue the excellent work of the previous EB. A core group of ASPHER representatives working with the editorial team provided important support over the transition period. The previous policies of theme issues will be augmented by accepting individually submitted review papers which fit in with topical issues. PHR will strive to achieve monthly issues, yielding 30 articles annually, with free for online access, including archived previous volumes.The Opening Issue of PHR in 2015The initial issue is a follow up to the 2012 volume on public health ethics. A second issue of PHR on this theme within four years of a previous issue is based on the initiative of ASPHER to prepare curriculum material for formal and informal teaching of public health ethics in the European context as explained in the Lee and Royo-Bordonada editorial [2], and Towards Public Health Ethics [3]. A European oriented curriculum will need relevant case studies for the organized teaching of ethics in public health education programs for undergraduate and graduate degree programs in Europe, in parallel to current Canadian and U.S. initiatives in public health ethics case studies [4].Public health has many enormous achievements to its credit adding many years of life expectancy globally. But public health has also suffered from past ethical failures of staggering proportions in the 20th century through association with eugenics. The most egregious of these was the active and passive participation of medical and public health professionals in interpretations of eugenics which led to mass sterilization and the murder of handicapped people, and participation in the Holocaust perpetrated by Nazi Germany. …

This perspective is part of an international effort to improve epidemiological models with the goal of reducing the unintended consequences of infectious disease interventions. The scenarios in which models are applied often involve difficult trade-offs that are well recognised in public health ethics. Unless these trade-offs are explicitly accounted for, models risk overlooking contested ethical choices and values, leading to an increased risk of unintended consequences. We argue that such risks could be reduced if modellers were more aware of ethical frameworks and had the capacity to explicitly account for the relevant values in their models. We propose that public health ethics can provide a conceptual foundation for developing this capacity. After reviewing relevant concepts in public health and clinical ethics, we discuss examples from the COVID-19 pandemic to illustrate the current separation between public health ethics and infectious disease modelling. We conclude by describing practical steps to build the capacity for ethically aware modelling. Developing this capacity constitutes a critical step towards ethical practice in computational modelling of public health interventions, which will require collaboration with experts on public health ethics, decision support, behavioural interventions, and social determinants of health, as well as direct consultation with communities and policy makers.

This anthology of articles on ethics in epidemiology and public health practice substantially updates and expands the topics dealt with in the first edition of the book. The topics covered in this second edition include ethical issues in epidemiologic research, public health practice, ethics instruction, and ethics guidelines for epidemiologists. Several theoretical and applied aspects of public health ethics at public health agencies and institutions are also dealt with including general ethical principles and organizational ethics. Since the publication of the first edition of this book, there have been several notable developments in ethics, epidemiology, and public health practice. These include the publication of scholarly articles outlining the principles and terrain of public health ethics, new books on public health ethics and closely related topics, and the release of important papers on ethical issues in public health ethics (e.g., a consultation paper prepared by the Nuffield Council on Bioethics in Great Britain). However, few resources have been available that articulate ethical issues in both epidemiologic research and in public health practice.

John Coggon argues that the important question for analysts in the fields of public health law and ethics is 'what makes health public?' He offers a conceptual and analytic scrutiny of the salient issues raised by this question, outlines the concepts entailed in, or denoted by, the term 'public health' and argues why and how normative analyses in public health are inquiries in political theory. The arguments expose and explain the political claims inherent in key works in public health ethics. Coggon then develops and defends a particular understanding of political liberalism, describing its implications for critical study of public health policies and practices. Covering important works from legal, moral, and political theory, public health, public health law and ethics, and bioethics, this is a foundational text for scholars, practitioners and policy bodies interested in freedoms, rights and responsibilities relating to health.

Review Question: This review aims to answer the following specific question: What are nurses’ experiences of preparing for and managing the ethical challenges posed by catastrophic public health emergencies and health care disasters? Review Purpose/Objectives: The purpose of this systematic review is to systematically review and synthesise research literature reporting nurses’ experiences of ethical preparedness for dealing with catastrophic public health emergencies and health care disasters and the ethical quandaries that may arise during such events. INCLUSION CRITERIA: Types of Participants: The review will consider publications that include nurses registered or authorised under a given country’s state of emergency provisions to practice in jurisdictions in which a public health emergency (e.g. pandemic influenza) or sudden‐onset mass casualty health care disaster (e.g. flood, hurricane, earthquake, tsunami, volcanic eruption, terrorist attack) have occurred, or may occur. Phenomena of interest: This review will examine the phenomenon of nurses’ experiences of preparing for and/or managing ethical issues arising during a public health emergency or health care disaster. Consideration will be given to, but not be limited to nurse preparation for and management of ethical issues associated with: development of local public health emergency (including pandemic influenza) and sudden‐onset health care disaster plans provision of first health care contact for the general public personal protection and correct use of safety equipment providing front line clinical care providing community and primary health care assistance with containment measures triaging in a range of settings, including general practices, community health centres, and local hospitals maintaining infection control vaccinations informing the public work attendance.