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Decision-Making Given
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Author: Madeline M. Roberts MPH, PhD The closing general session of the 2022 APHA Conference was titled “Building Public Health Capacity Through an Ethical Lens to Address Social Challenges.” It began with a keynote presentation by Dr. Lisa Lee entitled “Public Health’s Ethical Lens” and concluded with a panel discussion including Drs. Howard Koh, Nancy Krieger, Rueben Warren, David Holtgrave, and Lisa Lee. Lee’s stated aim for the session was that the audience leave with “a common understanding of what we—the public health profession—mean when we say ‘ethics’.” This session allowed the listener to zoom out and consider how the scope of ethics is much broader than simply doing the right thing. Rather, it is utilizing a framework—and communicating clearly and openly about this framework—to reach a decision in the face of conflicting values and incomplete information or evidence. Dr. Lee summarized this as taking the “best course of action given what we know at present,” and underscored the need to do this transparently for the communities involved. In her presentation, Lee suggested that public health ethics is two things, both a noun and a verb. As a noun, it is moral governance, which she defined as “a constellation of values that motivate our work: equity, respect for human rights, common good, solidarity, and justice,” noting there are differences in values for different people. As a verb, as action we take, public health ethics is “reasoning and decision making in ethically challenging situations…the application of a decision-making framework that helps us decide a course of action when values conflict.” She went on to say that ethics is often not as simple as right versus wrong: “Even when we’re faced in public health with several not great choices, we still have to act, we still have to decide something, because public health if nothing else is a field of action.” In nebulous situations, it is insufficient to lead with our instincts or what we personally think is best. Lee quoted Jim Swearengen as having said, “Professional judgment is the judgment of the profession, not the professional.” Lee offered that the same is true of public health ethics. She concluded her presentation by discussing the collective moral compass of public health, the Public Health Code of Ethics, adopted by APHA in 2019 from a multi-disciplinary task force. It contains six core values, eight considerations for public health decision making, and a framework for ethics in difficult decisions with conflicting values. Principles from The Public Health Code of Ethics
The panel discussion was moderated by Dr. Howard Koh, and included Drs. Nancy Krieger, David Holtgrave, Rueben Warren, and Lisa Lee. In her comments on ethical public health decision-making and social determinants of health, Dr. Krieger noted that social determinants arise out of societal relationships of power and property. She suggested that a fundamental ethical duty in public health is to clearly name and call out those who make policies that do not allow for equity to exist. She also underscored the need for a more robust data infrastructure—“to understand the health of people we need the data to have the evidence to make the decisions.” Dr. Warren’s panel comments were helpful in articulating the gap between good intentions and measurable ethical action, “Everyone I know thinks they are ethical…we need to operationalize what that really means.” An operational definition of ethical conduct would allow us to move from reacting to ethical violations toward preventing them. Warren advocated for community engagement and discussed how public health ethics is more than just the principles of autonomy, benevolence, and justice: “The intention to do good is very different from doing good…doing good that you can measure.” In public health we should aim, as he put it, to “measurably do good beyond your intentions.” Dr. Holtgrave discussed how part of transparency is being clear with the public about what we are aiming to achieve, especially when resources are limited and the need is great, “It’s important to highlight, what are those metrics that we are going to go after as a nation?” He gave an example from the Office of National Drug Control Policy where they have created a publicly viewable dashboard on the website for anyone to see what progress is being made and to what ends. He discussed the need for transparency in stating what the goals are, as well as the need to evaluate how we think about health disparities and health equity as it relates to stated goals.
In a field that deals with
health promotion and protection for all manner of communities, and often
centers underserved populations, this session was helpful in causing the
listener to consider the difference between assuming one is ethical by
simply being in public health and measurable ethical action. This
conversation set the stage well for APHA 2023, for which the theme is
“Overcoming Social and Ethical Challenges.”
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