Ethical Analysis in Public Health Practice

Background: Despite a burgeoning public health ethics literature, there are few empirical studies of public health practitioners' ethical perspectives, and how they identify and resolve ethical dilemmas they encounter in their work. There is no dominant, comprehensive public health ethics framework for use in research, education and practice. Methods: This project used a sequential mixed-model approach with mixed-method studies. A comprehensive literature review and a series of interviews using convenience-within-frame sampling were used to develop a framework and guide subsequent studies. Using an integrated knowledge translation approach, two formative and three core studies used web-based and paper-based surveys to gather quasi-representative data from public health practitioners (PHPs), including public health physicians, nurses, inspectors, policy-makers and trainees as part of conferences and educational workshops. The surveys solicited responses to questions regarding PHPs perspectives on ethical aspects of public health practice and dilemmas they encountered, as well as responses to several scenarios. Qualitative data were coded into open themes. Quantitative data were analysed using SPSS 21. Data between groups were compared when appropriate and significant differences were noted. Results: The Public Health Ethical Reflection Matrix (PHERM) Framework was developed and data were collected from 8 interviews and surveys of 16 Canadian Public Health Physician trainees, 70 Public health ethics conference attendees, 76 Canadian Public Health Physicians, 52 Public Health nurses and 456 Public Health Inspectors. There were areas of similarity and of remarkable heterogeneity of responses within and between professional groups regarding prioritization of values and meta-ethical justification of ethical norms. Specifically, respondents were divided with regards to prioritization of overarching goals and specific values, the relative importance of different value types, respecting the law, and treatment of marginalized and vulnerable populations. Ethical dilemmas encountered by participants and approaches to dilemma resolution also varied considerably. Conclusions: Ethical dilemmas were prevalent in public health practice with public health practitioners holding a variety of disparate views regarding ethics in public health across PHERM domains. Explicit acknowledgement and exploration of these views may improve ethical decision-making in practice. The PHERM Framework appears to be an effective way of approaching complex public health ethical dilemmas. Further applied research is necessary to confirm the PHERM Tool utility in practice.Ph.D