Question

Describe ethical dilemmas associated with the current state of population health and health disparities.

Answer 1

Ethical Dilemma

An ethical dilemma is a decision-making problem between two possible moral imperatives, neither of which is unambiguously acceptable or preferable. The complexity arises out of the situational conflict in which obeying one would result in transgressing another.

These are some public health areas where WHO is involved in providing leadership and guidance on the ethical issues involved.

According to WHO the major ethical dilemmas related to population health

Outbreaks and emergencies

Responses to epidemics, emergencies, and disasters raise many ethical issues for the people involved, including public health specialists and policymakers. WHO has been developing guidelines and training materials on ethical issues arising in different types of epidemics, such as pandemic influenza, Ebola, and Zika. The organization supports its Member States in capacity-building in this area and carries out pieces of training and workshops in countries.

Ethical standards and procedures for research with human beings

Research ethics govern the standards of conduct for scientific researchers. It is important to adhere to ethical principles to protect the dignity, rights, and welfare of research participants.

As such, all research involving human beings should be reviewed by an ethics committee to ensure that the appropriate ethical standards are being upheld. Discussion of the ethical principles of beneficence, justice, and autonomy are central to ethical review.

Developing guidelines for public health surveillance

Surveillance is one of the most fundamental activities of public health, involving different areas and practices such as non-communicable disease registers, outbreak investigations, and health systems research. Public health surveillance raises multiple ethical issues concerning, among others, the use/non-use of informed consent or the provision/non-provision of standards of care.

Ethical issues in tuberculosis care and control

The prevention, care, and control of infectious diseases, including tuberculosis (TB), raise several ethical issues. These include questions about the equitable distribution of resources, protection of vulnerable groups, respect for patient choice of treatment options and solidarity between communities during outbreaks. These ethical issues influence how TB care and control programs are planned and implemented.

Human Genome editing

14 December 2018 -- WHO is establishing a global multi-disciplinary expert panel to examine the scientific, ethical, social and legal challenges associated with human genome editing (both somatic and germ cell). The panel will review the current literature on the state of the research and its applications, and societal attitudes towards the different uses of this technology. WHO will then receive advice from the panel on appropriate oversight and governance mechanisms, both at the national and global levels. Core to this work will be understanding how to promote transparency and trustworthy practices and how to ensure appropriate risk/benefit assessments are performed before any decision on authorization.

Human organ and tissue transplantation

Transplantation of human organs and tissues, which saves many lives and restores essential functions for many otherwise untreatable patients, both in developing and developed countries, has been a topic for ethical scrutiny and health care policy-making for more than thirty years. These issues include the source and manner of organ procurement, as well as the allocation of organs within health systems

HIV/AIDS

From its outset, the HIV epidemic has raised many ethical challenges for public health officials, researchers, and clinicians, reaching from macro-level policy to micro-level clinical decisions. WHO has been supporting its Member States in addressing these ethical issues, working on equitable access to HIV services, ethical issues in testing and counseling, HIV surveillance and clinical trials.

More recently, the introduction of pre-exposure prophylaxis (PrEP), and the early initiation of ARVs in individuals with HIV infection has raised several complex ethical issues in making strategic allocations of financial and programmatic resources for HIV prevention and treatment.

Health Systems and Implementation Research

Implementation Research (IR) is a form of inquiry into the process of translating clinical and public health evidence into practice. It addresses issues of improving access to and use of specific interventions within a local context of implementation. There is an ethical imperative to conduct implementation research as there is a need to understand access, acceptability, reach and utilization issues in a local context.

Biobanking

The Global Health Ethics Unit has been collaborating with various departments at WHO to develop ethical oversight and governance mechanisms for the collection, storage, and dissemination of samples and biospecimen.

Big data and artificial intelligence

Digital technologies, machine learning and Artificial Intelligence (AI) are revolutionizing the fields of medicine, research, and public health. While holding great promise, this rapidly developing field raises ethical, legal and social concerns, e.g. regarding equitable access, privacy, appropriate uses and users, liability and bias and inclusiveness. These issues are trans-national, as capturing, sharing and using data generated or used by these technologies goes beyond national boundaries. The tools, methods, and technologies used in “Big Data” and AI are being applied to improve health services and systems. However, many questions remain unanswered concerning the ethical development and use of these technologies, including how low- and middle-income countries will benefit from AI developments

Immunization

Immunization raises a host of challenging ethical questions that researchers, governments, funders, pharmaceutical companies, and communities must confront.

Before vaccines can be administered, the preliminary phases of vaccine research are fraught with ethical dilemmas, particularly during and following the implementation of clinical trials. After licensure, many challenging questions arise related to the delivery of vaccines locally, regionally, and nationally.

An important ethical debate revolves around the permissibility of the use of placebo in vaccine trials. In 2013, WHO organized an international consultation to discuss this issue and the way forward.

Good governance in medicines

Good governance in the pharmaceutical sector includes measures to ensure a transparent process of drug procurement, drug control, rational drug use and access to medicines in an equitable manner to all sections of the community. Integrity and ethical governance measures are essential for effective health care delivery in a health system.
For some years, the Global Health Ethics Unit has been supporting the Department of Essential Medicines and Health Products in the development of the Good Governance for Medicine (GGM) framework

Vector-borne diseases

The recent outbreak of the Zika virus was deemed a Public Health Emergency of International Concern by the WHO Emergency Committee and continues to receive heightened attention. Zika has raised many specific ethical issues, in particular regarding pregnancy. At the same time, it has highlighted ethical issues that arise in vector-borne diseases (VBDs) more generally. Attention to Zika is thus an opportunity not only to address ethical concerns about an ongoing epidemic outbreak and its consequences but to broaden our field of inquiry to VBDs as such.

Aging

In 2015, the number of people aged 60 years and over (‘older persons’) worldwide was estimated to be about 900 million. The size of this age group is expected to grow to 2 billion by 2050. Furthermore, the current estimated number of people aged over 80 years is about 125 million. And this specific age group is estimated to grow to about 434 million by 2050, with about 120 million people living in China alone. Importantly, by 2050, 80% of all people aged 60 and over (about 1.6 billion) will be living in low- and middle-income countries.

THE ETHICAL IMPLICATIONS OF POPULATION GROWTH

Population Matters opposes coercive population restraint policies on ethical grounds, in defense of individual human rights, especially women’s rights. At the same time, population growth raises important ethical issues around the balance between reproductive rights and social and environmental responsibilities.

1. Inter-generational ethics: It is a fact that current growth (10.000 more per hour) will stop one day, simply because a finite planet cannot sustain an infinite number of people. But it can only stop in one of two ways: either sooner, the humane way, by fewer births - family planning backed by policy to make it available and encourage people to use it; or later, the 'natural' way, by more deaths - famine, disease, and predation/war. Campaigners against the former are in practice campaigning for the latter. We owe it to our children to prevent this.
2. International ethics: This is not just an issue for poor countries. The UK population is projected to grow by 10 million in the next 22 years - that's '10 more Birminghams'. England is already the most overcrowded country in Europe, taking far more than our share of our planet’s natural resources. Each of us does far more damage to the planet than any poor African; every extra Briton, for instance, has the carbon footprint of twenty-two more Malawians – and the poor will suffer first and worst from climate change. We owe it to others to stabilize our numbers too (and our resource-consumption), and then reduce them to a sustainable level.

3. Reproductive Ethics: It is also a fact that if two people with two living children have a third child, they will ratchet up the population of the planet, and thus: ratchet up damage to the environment; bring nearer the day of serious ecological failure; ratchet down everyone else's share of dwindling natural resources to cope with this. So individual decisions to create a whole extra lifetime of impacts affect everyone else (including their children) – far more than any other environmentally damaging decision they make. We need to be aware of the ethical implications of having large families; sex education in schools should include it.

4. Humanitarian Ethics: Some 220 million women worldwide lack access to family planning, and 40% of pregnancies are unintended. There are some 50,000 deaths from unsafe abortions each year; while the women dying from pregnancy-related causes is equivalent to 4 full jetliners crashing every day. The close correlation of high fertility rates with high maternal and child mortality is well established - every mother on $1 per day knows that the family will be better fed if there are three children round the table rather than ten. Universal access to family planning is Millennium Development Goal 5b; coercive pregnancy through lack of it is an abuse of women’s rights too. As UNICEF said: "Family planning could bring more benefits to more people at less cost than any other known technology". It should be a very high priority.

5. Inter-species ethics: The very recent population explosion since the industrial revolution is causing the current '6th major global extinction', as humans occupy, degrade, pollute and destroy wildlife habitats. Other creatures have as much right to occupy the planet as we do.

5. Political ethics: For all the above reasons, the government should state a national goal of stabilizing and then reducing UK numbers to a sustainable level, by non-coercive means, as soon as possible; and give top priority to family planning and women’s education and empowerment programs in the development aid budget.

Disparities in Population

Health

Erika Blacksher published an article related to Disparities in population health - in Bioethics. In it she says Public health experts have

known since the turn of the twentieth century that poor health and poverty go together Now, one hundred years later,

that understanding is more refined. Thousands of studies have confirmed a “social gradient” in health wherein socially disadvantaged groups – whether measured by race, socioeconomic status (SES), or other indices of hierarchy – shoulder a disproportionate burden of health deficits.

This gradient in health does not plateau once a certain level of income and wealth is attained. Rather, it extends into the highest reaches of socioeconomic strata and remains after controlling for risk factors.2 Each rung up or down the ladder yields generally better or worse health, respectively.

A Response to Disparities and Dilemmas

An article of Tarris Rosell says an incident

Ted, a young working father, shows up in the emergency room with symptoms that lead eventually to a diagnosis of lymphoma. His earnings are little more than minimum wage. He has no employee healthcare benefits, and he is determined to be ineligible for Medicaid or other public insurance. Hospital personnel refer Ted for follow-up care to a local free health clinic without oncology services. The medical director there worries that without access to appropriate treatment, Ted will die.

The uninsured or underinsured who do receive healthcare may be billed into bankruptcy or forced to accept charitable care. Two-thirds of the uninsured who obtain free care do so from the general pool of primary care providers (P. J. Cunningham, JAMA 1998; 280:921-927). This service is provided quietly — it is typically unbilled, unreported, and unrecognized. Emergency departments often become the primary care provider for those who cannot get into the system any other way. Others of the uninsured find some access to primary care through the “safety net” of public health departments, public hospitals, and free (or sliding fee scale) nonprofit health clinics