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 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 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 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 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).