This document provides an overview of different ethical theories and principles relevant to public health practice and research. It discusses major philosophical approaches like deontology, utilitarianism, and virtue ethics. It also covers religious approaches like Islamic ethics and key principles in public health ethics around concepts like autonomy, beneficence, non-maleficence, and justice. Specific issues like informed consent, conflicts of interest, and resource allocation are examined through the lens of these different theories. The document aims to help public health practitioners analyze and approach ethical issues in their work.

1. Ethical principles and theories and the core
professional public health values
EMPHNET
Ghaiath M. A. Hussein
MBBS, MHSc. (Bioethics), PhD Researcher
Email: ghaiathme@gmail.com
Regency Palace hotel, Amman, Jordan
15-19 June, 2014

2. Module’s objectives
• Differentiate between the main ethical
theories
• Identify key ethical principles and values
relevant to public health practice and research
• Present a moral argument on an ethical issue
related to public health based on the ethical
theories and values

3. Module’s Outline
• How do we (as humans and public health
practitioners) tell right from wrong?
– Philosophical approaches
– Religious approach
• Examples of the main ethical issues
– Informed consent
– Conflicts of interest
– Resource allocation

4. How to approach an ethical issue?

5. Ethical Guidance in PHE
Philosophical
• Deontological
• Utilitarian (act &
rule)
• Rights-based
• Virtue
• Casuistry
• Social-contract
• Principlism
Religious
• Islamic ethics &
jurisprudence
(Purposes of Law
‘Sharia’)
• Christian ethics
• Jewish Ethics
• ?Oriental
Philosophies
(Buddhist,
Confucian, etc.)
Guiding Principles
• Utility
• Efficiency
• Liberty
• Transparency
• Participation
• Review and
revisability
• Effectiveness
• Fairness
• Reciprocity
• Solidarity

6. Deontology & Rights-based
ethics
• Deontology :
– Deontology is duty-based, people should act so as to
fulfill their duties to others; acts should always
follow a set of maxims (e.g. do not lie); and less
concerned with the act’s consequences.
• Rights-based ethics:
– involves a larger number of principles and is
addressed more to the actions of institutions and
governments, e.g. Universal Declaration on Bioethics
and Human Rights, (UNESCO) in October 2005. It
provides more binding legal rights

7. Consequentialism
(utilitarianism)
• Consequentialism (utilitarianism)
– the right action is that which produces the
greatest sum of pleasure in the relevant
population,
• Act utilitarianism: a person should act in the
way that produces the best outcome;
• Rule utilitarianism: looks at the consequences
of general rules instead of the consequences
of individual acts

8. Feminist ethics and Casuistry
Feminist ethics: (Ethics of Care) commitment to
correcting male biases (e.g. women’s subordination is
morally wrong) and that the moral experience of
women is as worthy of respect as that of men.
Casuistry: The greatest confidence in our moral
judgments resides not at the level of theory, where
we endlessly disagree, but rather at the level of the
case, where our intuitions often converge without
the benefit of theory.

9. Virtue ethics
It emphasizes the virtues, or moral
character (not duties or consequences)
Someone in need should be helped. Agree?

10. “Contractarianism”: Social
Contract Theory
Agreement (or consent) of all individuals subject to
collectively enforced social arrangements shows that those
arrangements have some normative property (e.g. legitimate,
just, obligating, etc.). (http://plato.stanford.edu/entries/contractarianism-contemporary/)
1. Political theory: claims that legitimate authority of
government must derive from the consent of the
governed, where the form and content of this consent
derives from the idea of contract or mutual agreement.
2. The moral theory: claims that moral norms derive their
normative force from the idea of contract or mutual
agreement.

11. Rawl’s theory of Justice
Rawl’s (Theory of Justice), requires two main
conditions for this ‘contract’:
1. Equality of moral persons: Each person is
rational, self-interested and have an equal right
to the most extensive total system of equal basic
liberties.
2. Veil of ignorance : morally adequate principles
of justice are those principles people would
agree to in an original position which is
essentially characterised by this veil of
ignorance.

12. Principlism
• Principle-Based Theories
– Principlism is one way of approaching
professional deontology
• Examples:
– Hippocrates’ oath (“First, do no harm” or “Primum non nocere”)
– Belmont Report, produced in 1978 (three principles)
– Beauchamp and Childress in 2001 (four principles—beneficence, non-maleficence,
respect for persons, and justice)

13. The ‘4 principles’ model
• Autonomy: respect humans'
ability to choose,
• Beneficence: Do Good for others,
• Nonmaleficence (Do No Harm), &
• Justice

14. Islamic Bioethics

15. Sources of Islamic Morality
Main Sources
1) The Koran
2) The Sunna
Secondary Sources
1) Unanimous agreement of Islamic jurists (Ijmaa)
2) Acceptance by the majority of trusted scholars (Rayul Jomhour)
3) Measurement/Analogy (Qiyas)
4) Remediation (Maslaha), (Istishab)

16. Goals of Islamic Regulations
The five purposes of Sharia are to preserve person’s:
1. Religion
2. Soul
3. Mind
4. Wealth and
5. Progeny
All Islamic legislations came to achieve these goals.

17. What is Islamic Bioethics?
It is the methodology of
defining, analysing and resolving the ethical issues that arise in
healthcare practice, or research;
based on the Islamic moral and legislative sources (Koran,
Sunna & Ijtihad); and
aims at achieving the goals of Islamic morality (i.e. preservation
of human’s religion, soul, mind, wealth & progeny )

18. Major Fiqhi Principles
1. The principle of Intention (Qasd): Each action is judged by the
intention behind it
2. The principle of Certainty (Yaqeen): Certainty can not be removed
by doubt
3. The principle of Injury/Harm (Dharar):
 Injury should be relieved; An individual should not harm others
or be harmed by others
 An injury is not relieved by inflicting or causing a harm of the
same degree
 Prevention of harm has priority over pursuit of a benefit of
equal worth
 the lesser harm is committed

19. Major Fiqhi Islamic Principles (2)
4. The principle of Hardship (Mashaqqat): Difficulty calls forth
ease, Necessity (Dharuraat) legalizes the prohibited
5. The principle of - Custom or precedent (Urf): Custom is
recognized as a source of law on which legal rulings are based
unless contradicted specifically by text from the main
legislative sources, i.e. Koran and Sunna.

20. The five major Fiqhi principles and their
main ‘sub-principles’

21. What is your ‘favourite’ theory?
Why?

22. • Utility: acting so as to produce the greatest
good.
• Efficiency: calls for minimizing the resources
needed to produce a particular result or
maximizing the result that can be produced
from a particular set of resources.
• Liberty: one should impose the least burden on
personal self-determination that is necessary to
achieve a legitimate goal

23. Guiding ethical principles (2)
• Fairness: “treating like cases alike”
• Reciprocity: individuals (professionals) accept
of the risk in executing their duties would
engender reciprocal duties on the part of the
community to them
• Proportionality: actions taken proportional to
need

24. EXAMPLES OF PRACTICAL
IMPLEMENTATION OF THESE
THEORIES

25. Informed Consent
• Definition(s):
– Autonomous authorization of a medical
intervention…by individual
patients/participants” (Beauchamp and Faden, 2004)
– It's the practical expression of patient's
autonomy, and the respect for him/her
personality

26. Conditions for informed
consent
Disclosure
Capacity Voluntariness

27. Conditions for FIC
1. Disclosure: This refers to the process during which the
health care provider or researcher provides information
about the proposed intervention or research to the
participant.
2. Capacity: Refers to the presence of a group/set of
functional abilities a person needs to possess in order to
make a specific decisions (Griso and Applebaum, 1998). These
include: to UNDERSTAND the relevant information, & to APPRECIATE
the relatively foreseeable consequences of the various available
options available.
3. Voluntariness: Refers to a participant’s right to make
participation decisions free of any undue influence.

28. Conflict of interests
• What is an interest?
• Examples of interests:
– Financial interests
– Career and Academic interests
– Social interests
• How to manage COIs?
Your thoughts?

29. What is an interest?
• An interest may be defined as a commitment,
goal, or value held by an individual or an
institution.
• Examples include a research project to be
completed, gaining status through promotion
or recognition, and protecting the
environment. Interests are pursued in the
setting of social interactions.

30. What is COI?
• COI exists when two or more contradictory
interests relate to an activity by an individual
or an institution.
• Conflicts of interest are “situations in which
financial or other personal considerations may
compromise, or have the appearance of
compromising, an investigator’s judgement in
conducting or reporting research.” AAMC,
1990

31. What is COI? Cont.
• “A conflict of interest in research exists when
the individual has interests in the outcome of
the research that may lead to a personal
advantage and that might therefore, in
actuality or appearance compromise the
integrity of the research.”
NAS, Integrity in Scientific Research

32. Rationing and Resource allocation

33. Exercise… Share this cake FAIRLY

34. Back to theories!!
• Utilitarianism:
– Theory: resources being allocated to less expensive
treatments or services that provide the greatest
benefit.
– Practice: QALY.
• Equity and Distributive Justice
– Theory: “equals should be treated equally, and
unequals treated unequally in proportion to the
relevant inequalities”. The need not only the benefit
gained from an intervention.
– Practice: ensure that those in poorest health, or
greatest need

35. Back to the principles!!
• Autonomy:
– individuals have a right to determine/choose what is in their
own best interest
• Beneficence/Non-maleficence:
– Healthcare providers should act in the interest of their
clients/patients and NOT to harm them
• ‘distributive’ Justice/fairness:
– All groups have an equal right to health services regardless
of race, gender, age, income, or any other characteristic.

36. In practice…
• What does resource allocation affect? How?
Breadth
• the population
covered?
• application of criteria
• means-testing (e.g.,
excluding those with
higher incomes),
• employment (e.g.,
excluding self-employed
people),
• excluding people from
eligibility (e.g., those
who do not meet
certain requirements),
• or by allowing people
to opt out.
Scope
• Which services?
• excluding services
from the benefits
package
• effectiveness,
• comparative
effectiveness,
• cost-effectiveness,
• health technology
assessments (HTAs),
• clinical guidelines or
quality assurance
Depth
• extent or cost share to
which services are
covered
• selective charges (co-payments)
for
inefficient services,
• reduced charges for
especially valuable
ones (value-based
insurance design)

37. Ezekiel J. Emanuel" Justice and Managed Care: Four Principles for the
Just Allocation of Health Care Resources,” Hastings Center Report 30,
no. 3 (2000): 8-16.
Daniels N, Sabin JE. The ethics of accountability in managed care
reform. Health Aff (Millwood) 17[5], 50-64. 1998
THEORETICAL MODELS FOR
RESOURCE ALLOCATION

38. Emanuel’s Justice and Managed Care
• Improving Health Should Be the Primary Goal:
– The allocation of health care resources should aim at and be justified
by the improvement in people's health
• Patients and Members Should Be Informed:
– Patients/community should be informed about the allocation of
health care resources and the underlying data and justification for
the allocation.
• Patients and Members Should Have the Opportunity to
Consent.
– Patients/community should be given the opportunity to consent to
the allocation of health care resources that will affect them.
• Conflicts of Interest Should Be Minimized:
– People entrusted to allocate health care resources should not make
allocating decisions under conditions that could reasonably be
expected to be influenced by direct, personal financial benefits or
penalties.

39. Accountability for
Reasonableness (Daniel & Sabin)
Condition Description
Relevance • Priority setting decisions must rest on reasons
(including evidence and principles) that fair-minded
participants (stakeholders) can agree are relevant
• These can involve managers, clinicians, patients, and
consumers in general (three key foci are underlined)
Publicity Priority setting decisions and their rationales must be
publicly accessible
Appeals The priority setting process must include a mechanism for
revising decisions in light of further evidence or principles
that other stakeholders might contribute
Enforcement There must be voluntary or public regulation of the
process to ensure that the first three conditions are met

40. Let’s give it a thought!
• Within its efforts to control the spread of
Pandemic Influenza A H1N1 during the Hajj
season (2010), the Saudi government was
able to provide a total of 2,500,000 doses of
the newly produced vaccine.
• The pilgrims are estimated to be 3,500,000;
the working staff who are in contact with
pilgrims (entries, security & health) are about
120,000 persons
• Who should have the vaccine? Who’s first?

41. References
• APHA Code of ethics:
http://www.apha.org/NR/rdonlyres/1CED3CEA-287E-4185-
9CBD-BD405FC60856/0/ethicsbrochure.pdf
• Childress, James F. Et al., Public Health Ethics: Mapping the
Terrain, Journal of Law, Medicine and Ethics, 30 (2002): 170-
178.
• Daniels, N. and J. E. Sabin (2008). "Accountability for
reasonableness: an update." BMJ 337.
• Alex Friedman (2008). “Beyond Accountability for
Reasonableness”. Bioethics 22 (2), 101–112.
Doi:10.1111/J.1467-8519.2007.00605.X

42. Readings
• Verity C and Nicoll A. Consent, Confidentiality, and the threat
to public health surveillance. BMJ. 324: 1210-1213. May 2002.
• Myers et al. Privacy and Public Health at Risk: Public Health
Confidentiality in the Digital Age. AJPH. 98(5): 793-801. May
2008.
• O’Neil O. Informed Consent and Public Health. Phil. Trans. R.
Soc. Lond. B (2004) 359, 1133–1136.
• MacQueen K and Buehler J. Ethics, Practice, and Research in
Public Health. AJPH. 94(6): 928-931. June 2004.
• Miller, TE. Sage, WM. “Disclosing physician financial
incentives.” JAMA. 281 (15):1424-1430. April 1999.