Ethics in Public Health Practice

This chapter outlines a foundation for addressing ethical concerns in public health practice, which is informed by the approach of Alasdair MacIntyre's definition of practice. It talks about the goal of public health and views practice as directed toward fulfillment of that goal and related goods, providing a common ground on which to base further discussions. It cites the foundational values of public health practice in identifying the common moral governance. It also looks at a common element of recent arguments on the importance and value of health that is necessarily for human well-being and flourishing, a perspective essential for discussions of the role of human rights and equity in public health ethics. The chapter delves into considerations of value that are related to the ends of public health but are also critical in the assessment and implementation of how those ends are achieved. It highlights the task of ethics that involves a continuing examination of means and ends in an iterative process. Though written before the COVID-19 pandemic, the chapter addresses the importance of public health preparedness for disasters and pandemics, including an outline of Preventive Ethics as central to ethical planning and implementation of public health prevention and response.

Ethical challenges in management of critically ill pregnant patients with coronavirus disease 2019 (COVID-19)

Despite the overwhelming number of coronavirus disease 2019 (COVID-19) cases worldwide, data regarding the optimal clinical guidance in pregnant patients is not uniform or well established. As a result, clinical decisions to optimize maternal and fetal benefit, particularly in patients with critical COVID-19 in the early preterm period, continue to be a challenge for obstetricians. There is often uncertainty in clinical judgment about fetal monitoring, timing of delivery, and mode of delivery because of the challenge in balancing maternal and fetal interests in reducing morbidity and mortality. The obstetrician and critical care team should empower pregnant patients or their surrogate decision maker to make informed decisions in response to the team’s clinical evaluation. A clinically grounded ethical framework, based on the concepts of the moral management of medical uncertainty, beneficence-based obligations, and preventive ethics, should guide the decision-making process.

Ethics in obstetrics and gynaecology

Obstetrician-gynaecologists confront a wide range of ethical challenges in clinical practice. To guide obstetrician-gynaecologists in responding to these challenges in a responsible way, this chapter provides a concise overview based on the professional responsibility model of ethics in obstetrics and gynaecology. This model is based on the transformative contributions of Drs John Gregory (1724–1773) and Thomas Percival (1740–1804) to the global history of medical ethics. This model requires three commitments of physicians: to scientific and clinical competence; to the primacy of the patient’s health-related interests; and to sustaining medicine as a public trust rather than a self-interested merchant guild. This model emphasizes the professional virtues of doctors and ethical principles and the obligations to patients generated by these virtues and principles. The result is a model for ethics in obstetrics and gynaecology that is ethically sound and clinically comprehensive and practical. Taking a preventive ethics approach, this chapter provides ethically justified, practical guidance on the professional responsible management of clinical ethical challenges in gynaecology, in obstetrics, and in professionally responsible advocacy.

Clinician Perspectives on Challenges to Patient Centered Care at the End of Life

Discussions regarding patient preferences for resuscitation are often delayed and preferences may be neglected, leading to the receipt of unwanted medical care. To better understand barriers to the expression and realization of patients’ end of life wishes, a preventive ethics team in one Veterans Affairs Medical Center conducted a survey of physicians, nurses, social workers, and respiratory therapists. Surveys were analyzed through qualitative analysis, using sorting methodologies to identify themes. Analysis revealed barriers to patient wishes being identified and followed, including discomfort conducting end-of-life discussions, difficulty locating patients’ preferences in medical records, challenges with expiring do not resuscitate (DNR) orders, and confusion over terminology. Based on these findings, the preventive ethics team proposed new terminology for code status preferences, elimination of the local policy for expiration of DNR orders, and enhanced systems for storing and retrieving patients’ end-of-life preferences. Educational efforts were initiated to facilitate implementation of the proposed changes.

Pediatric Cancer Genetics Research and an Evolving Preventive Ethics Approach for Return of Results after Death of the Subject

In the pediatric clinical setting, the parent/guardian will almost always be the authorized representative and designated recipient of clinical and research results, making the issue of to whom results should be returned in the pediatric setting less complex than in adult settings. It is also clear that, in genomic research related to pediatric diseases such as cancer, results may be of considerable clinical, ethical, and personal significance for parents in a number of ways, including a genomic explanation of the origin of their child’s cancer, implications for the genetic testing and medical care of other siblings and of the parents themselves, and reproductive planning with regard to the recurrence risk for future children to have an increased risk of cancer. However, what remains unclear is which results should be disclosed, and under what circumstances, to parents of deceased children.