Ethical Decision Making in Public Health Practice

The purpose of this policy is to formally integrate ethical analysis and decision-making into the operations of NKY Health. This will be accomplished through an ethics framework to recognize, systematically evaluate and resolve ethical issues that may arise from the department’s programs, policies or services. By fostering a culture that supports the ethical practice of public health, NKY Health will make ethical decision-making more transparent and provide justification for decisions that are made.  

 This policy is in addition to the Code of Ethics. Violations of the Code of Ethics, personnel policies or other policies will be handled through procedures covered in those policies and are not covered by this policy.

Public health ethics: The application of relevant principles and values to public health decision making which guide public health actions when the best or right course of action is not immediately evident. It involves a systematic process to clarify, prioritize and justify possible courses of public health action based on ethical principles, values and beliefs of stakeholders, and scientific and other information. 

Ethical dilemma: A situation related to a specific program or service that involves conflict, choosing between equally desirable or undesirable alternatives, both of which are permitted under applicable state and federal laws, regulations, and/or agency policies; or balancing options, ethical principles or moral imperatives, which also are permitted under applicable state and federal laws, regulations, and/or agency policies.

The District Director of Health authorizes this policy, the designation of an Ethics Coordinator, and an NKY Health Ethics Advisory Committee. 

• NKY Health will foster a culture for the ethical practice of public health that includes ethical deliberation and decision-making as well as recognizing ethical challenges that arise in public health practice which may require a formal ethical decision-making process conducted by a neutral review body.

• NKY Health will maintain a public health ethics infrastructure consisting of the following components in order to appropriately address matters with an ethical component that cannot otherwise be resolved :

  • Public Health Code of Ethics: NKY Health formally adopts the Principles of the Ethical Practice of Public Health as delineated in Appendix A. This is in addition to the NKY Health Code of Ethics required by KRS 65A.070. 

  • Ethics Coordinator: The District Director of Health will designate an Ethics Coordinator. Duties will include maintaining familiarity with ethics tools and resources, arranging public health ethics training for NKY Health staff, and supporting the process for conducting ethical deliberations described in this policy. The coordinator will also chair the Ethics Advisory Committee, schedule meetings and reviews, notify members, facilitate meetings, and ensure completion of committee work products. The coordinator will maintain an Ethics Advisory Committee Google site as a repository for all relevant documents. These duties will be incorporated into the coordinator’s job description.

  • Staff Training: New employees will receive training in the Principles of the Ethical Practice of Public Health as part of new employee orientation. All staff will also receive training in these areas annually, acknowledging receipt in the department’s learning management system. The Ethics Coordinator and employees serving as core members of the Ethics Advisory Committee will also receive additional training utilizing the CDC’s Good Decision Making in Real Time course.

  • Ethics Advisory Committee: In the event of a complex ethical issue that cannot be resolved through other means, an Ethics Advisory Committee will convene to deliberate and make recommendations to the District Director of Health. The charter for the NKY Health Ethics Advisory Committee is found in Appendix B.

  • Ethical Analysis Framework: NKY Health will use the framework in Appendix C to review and deliberate ethical issues. This framework is recommended by the CDC as developed by Gaare-Bernheim R., et al.2 and modified with information from A Framework for Ethical Decision Making at the Markkula Center for Applied Ethics at Santa Clara University2.

  • Documentation: Records will be maintained of deliberations, conclusions, recommendations and results. 

1. When an employee believes that she/he has an ethical issue related to a program or service that needs to be addressed, she/he will discuss the issue with her/his supervisor as soon as possible.

2. The supervisor will report the issue as soon as possible with a recommended resolution to the Division Director for review. The Division Director may review the issue using the Ethical Analysis Framework (Appendix C) or some other appropriate decision-making process, and submit the issue and the proposed resolution to the District Director of Health for review and final approval.

3. The District Director of Health may resolve the issue using the Ethical Analysis Framework (Appendix C) or some other appropriate decision-making process or obtain a legal review, and if appropriate, refer it to the Ethics Coordinator for a review by the Ethics Advisory Committee. The District Director of Health will also notify the District Board of Health Chair that such action has been initiated.

   • Legal review: When the District Director of Health requests a legal review, the issue will be submitted to legal counsel to determine whether NKY Health and/or the Ethics Advisory Committee has legal authority to address the matter.

     • When the issue does not meet the legal parameters to be addressed, the concern is considered resolved and no further action will be taken.

     • When the issue meets the legal parameters to be addressed, then NKY Health legal counsel will provide a brief written legal assessment of the matter that considers federal, state, and local laws and ordinances as well as case law.

   • Ethics Coordinator conflict of interest: The Ethics Coordinator will complete the conflict of interest form (Appendix D). If the Ethics Coordinator has a conflict of interest, then the District Director of Health will appoint a different member of Senior Staff to serve in the coordinator role for the issue.

4. Upon legal review and referral by the District Director of Health, the Ethics Coordinator will arrange for the Ethics Advisory Committee to meet and review the issue, providing staff support for the committee in accordance with the committee charter (Appendix B).

   • Before the committee meeting, the Ethics Coordinator will gather relevant information from pertinent sources, develop a summary of the issue, and submit the summary along with the legal brief to the committee members.

   • The  Ethics Coordinator will also send conflict of interest forms to all members of the Ethics Advisory Committee. These are to be completed and returned to the Ethics Coordinator prior to the meeting.

   • When a committee member has a conflict of interest, the Ethics Coordinator will notify the District Director of Health who will identify an acceptable alternate member to serve. The Ethics Coordinator will document in the report that a substitution was made and the reason. 

5. When the Ethics Advisory Committee conducts a formal review, the Ethics Coordinator will provide an overview of the issue and lead the committee through the Ethical Analysis Framework (Appendix C). At the conclusion of the review, the committee’s key findings and recommendations will be submitted in writing to the District Director of Health for consideration.

6. The District Director of Health will make the final determination on all items reviewed by the Ethics Advisory Committee and may take any/all courses of action on the matter including no action or re-review. The appropriate member of Senior Staff will communicate results to the original requester.

7. The decision will be implemented. 

8. If the decision requires communications activities, the District Director of Health will notify the Public Information Manager and the District Board of Health Chair.

9. After implementation, the District Director of Health and applicable staff will review outcomes of the decision and discern the lessons learned. This will be documented and reported back to the committee.

10. The Ethics Coordinator will save the reports on the Ethics Advisory Committee Google site.

Records retention: A Google site titled, “Ethics Advisory Committee” will be established and maintained by the Ethics Coordinator as a repository for all ethics resources, training materials, documents, meeting summaries, and reports of the Ethics Advisory Committee. Records will be maintained in accordance with applicable administrative records retention schedules.

Staff training: Employees will acknowledge completion of training in the Health Department’s learning management system.

This policy and procedure will be reviewed by the Ethics Coordinator and District Director of Health annually and amended as needed.

• Code of Ethics

• Code of Ethics Acknowledgement Form

• Confidentiality, Privacy, Security, Sensitive Information, and HIPAA

1. Building an Ethics Infrastructure in Local Health Departments (2015). Retrieved October 13, 2017 from http://naccho.org/programs/public-health-infrastructure/ethics

2. Bernheim, R. G., Nieburg, P., & Bonnie, R. J. (2009). Ethics and the practice of public health. In R. A. Goodman, R. E. Hoffman, W. Lopez, G. W. Matthews, M. Rothstein, & K. Foster (Eds.), Law in Public Health Practice, 2nd edition. Chapter 5.  Oxford: Oxford University Press. DOI: http://dx.doi.org/10.1093/acprof:oso/9780195301489.003.0005

3. Velasquez, M.l, et al. (2009). A Framework for Ethical Decision Making. Markkula Center for Applied Ethics. Santa Clara, California. Santa Clara University Press.Retrieved October 13, 2017 from  https://www.scu.edu/ethics/ethics-resources/ethical-decision-making/a-framework-for-ethical-decision-making/

4. Principles of the Ethical Practice of Public Health (2002). Retrieved October 13, 2017 from https://www.apha.org/-/media/files/pdf/membergroups/ethics/ethics_brochure.ashx

5. Public Health Ethics. Retrieved October 13, 2017 from www.cdc.gov/od/science/integrity/phethics/

In order to engage in the ethical practice of public health, NKY Health will continuously strive to do the following:

• Focus on addressing the fundamental causes of disease and the requirements for health, aiming to prevent adverse health outcomes.

• Work towards improving the community’s health while considering the rights of individuals in the community to the extent possible.

• Develop and evaluate priorities and programs through processes that encourage input from community members.

• Work with the community to address the social determinants of health so that the basic resources and conditions necessary for health are accessible to all.

• Seek evidence-based best practices to implement effective programs and services that protect and promote health.

• Inform and educate communities about public health programs, services and actions that individuals can take to prevent disease, promote wellness or protect against health threats.

• Work to address health issues in a timely manner within the department’s resources, mandates and authority.

• Incorporate into programs and services a variety of approaches that respect diverse values, beliefs and cultures in the community.

• Implement programs and policies that support opportunities for healthy choices where we live, work and play.

• Protect the confidentiality of information that can bring harm to an individual or community if made public.

• Ensure the workforce is trained in the public health competencies and the essential functions of public health.

• Engage in collaborations and affiliations in ways that build the public’s trust and NKY Health's effectiveness in improving the community’s health.

 Based in part on Principles of the Ethical Practice of Public Health (2002). Retrieved October 13, 2017 from https://www.apha.org/-/media/files/pdf/membergroups/ethics_brochure.ashx

The purpose of the NKY Health Ethics Advisory Committee is to conduct formal ethics reviews of matters referred by the District Director of Health. The committee will provide recommendations back to the District Director of Health on these matters. Ethical reviews will focus on policies, systems and operations, not individual behavior that is covered by the department’s Code of Ethics or Guide to Personnel Policies.

The size and composition of the committee will depend on the nature of the issue being addressed and may change; however, the committee will be composed of no more than 12 members at any time. The District Director of Health will appoint members to serve on the committee who pertain to the deliberation of the specific issue.  

Core standing members will be the following:

• Division Directors, as applicable

• NKY Health Medical Director

• NKY Health legal counsel

• Health ethicist from local university/college or hospital system

Additional members may include any of the following as needed:

• NKY Health staff

• Physician from community, state or national level

• Nurse from community, state or national level

• Veterinarian

• Public health official from local, state or national level

• Local elected official

• Community stakeholder(s) relevant to the issue being discussed

• Law enforcement, animal control or other applicable county departments

• Emergency preparedness/management

• Water district, sanitation district representatives

• Business representative

• School representative

• Other as determined necessary

Members must not discuss the content or conclusions of ethics reviews with anyone outside of the committee, unless explicitly instructed to do so for the purpose of information-gathering. 

Chair: The Ethics Coordinator will serve as the chair of the committee, responsible for managing the logistics of the meetings and facilitating the deliberative process. The chair will also ensure that all members understand their roles and expectations, have input and are valued equally. The coordinator as chair is not a member of the committee and does not contribute to or vote in ethics reviews. In the event that the coordinator has a conflict of interest, the District Director of Health will appoint another member to serve as the coordinator and committee chair.

Recorder: A staff person will be assigned as the meeting recorder. The recorder will take notes and create the report of findings and recommendations. 

Ethicist: The ethicist will help to clarify the ethical dilemma posed and help with the analysis of alternate courses of action and their resulting consequences.

Legal counsel: NKY Health legal counsel will provide the committee with guidance regarding the legal considerations and limitations to ethics reviews. She/he will ensure that the committee is aware of relevant authorities and limitations on those authorities based on statutes, rules and legal precedents. 

1. Once the District Director of Health requests for a matter to be reviewed by the Ethics Advisory Committee, the coordinator will arrange for a committee meeting. 

2. Before the meeting, the coordinator will gather information pertinent to the issue from relevant sources, summarize the issue in writing, and submit the summary, legal brief and conflict of interest form to committee members.

3. At the meeting, the chair will provide an overview of the issue and facilitate moving the committee through the Ethical Analysis Framework.

4. The committee will deliberate and make every reasonable effort to reach consensus on the recommendation(s) for the District Director of Health. If consensus cannot be reached, a vote may be called by the chair and the recommendations will be forwarded to the District Director of Health.  In the event of a tie, the matter will be forwarded to the District Director of Health.

5. The recorder will summarize the findings and any recommendations and submit the report through the coordinator to the District Director of Health.

6. The District Director of Health will review the information and any recommendations and make the final decision about the issue.

7. The District Director of Health will provide a report back to the committee and Senior Staff on the final decision and any outcomes resulting from the implementation of the decision.

The District Director of Health will initiate a review of an ethical issue by requesting the Ethics Coordinator to assemble appropriate members of the Ethics Advisory Committee as soon as practicable. If an emergency review is necessary, the District Director of Health will direct the Ethics Coordinator to call a committee meeting as quickly as possible. At least three (3) committee members must participate in each analysis of an issue.

 Committee decisions will be made by consensus. In cases where consensus cannot be attained, a vote of the committee may be called by the chair. The recorder will prepare reports describing analysis outcomes and recommendations to be provided to the District Director of Health and committee members. The District Director of Health will have final authority for the decision. The final decision and results will be reported back to the committee and Senior Staff.

All committee members who are NKY Health employees will be required to participate in annual training in the principles of the ethical practice of public health in order to have a good foundational understanding of public health ethics. Initial training for these members will consist of the CDC’s Good Decision Making in Real Time: Public Health Ethics Training found at https://www.cdc.gov/od/science/integrity/phethics/trainingmaterials.htm. 

The committee will meet for specific cases, but if a case has not been reviewed in 12 months time, core members may meet for practicing the process on sample cases.

All documents and reports of the Ethics Advisory Committee will be retained on the committee’s Google site in accordance with the required retention schedule. 

NKY Health will analyze ethical issues in public health using the following steps:

1.  Recognize an ethical issue

   • Could this situation be damaging to someone or some group? Does this decision involve a choice between a good and bad alternative, or between two “goods” or between two “bads”?

   • Is this issue about more than what is legal or what is most efficient? If so, how?

2.  Gather information - Analyze the ethical issues in the situation

   • What are the relevant facts? What are the public health risks and harms of concern?

   • What are the public health goals?

   • Who are the stakeholders (what individuals/groups have an important stake in the outcome)? What is their stake? Are some concerns more important than others? Why?

   • Is the source or scope of legal authority in question?

   • Are precedent cases or the historical context relevant?

   • Do professional codes of ethics provide guidance?

3.  Evaluate the ethical dimensions of the alternate courses of public health action

   • What are the options for acting? Have all the relevant persons and groups been consulted?

   • Does a particular action produce the most benefits and do the least harm? (Utility approach)

   • Which option treats people equally - benefits and burdens spread fairly? (Justice approach)

   • Which option best respects the rights of all who have a stake – their individual interests and choices – autonomy, liberty and privacy? (Rights approach)

   • Which option best serves the community as a whole, not just some? (Common good approach)

   • Which option respects professional and civic roles and values, such as transparency, honesty, trustworthiness, consensus-building, promise-keeping, protection of confidentiality, and protection of vulnerable individuals and communities from undue stigmatization? (Respect for legitimate public institutions approach)

4.  Make a decision as a recommendation

   • Which option best addresses the situation given all these ethical approaches?

5.  Provide justification for a particular recommendation for public health action

   • Effectiveness: Describe how the public health goal is likely to be accomplished by this action.

   • Proportionality: Describe how the anticipated benefits of the action outweigh the infringed moral considerations of other stakeholders.

   • Necessity: Describe how it was necessary to override the conflicting ethical claims in order to achieve the public health goal.

   • Least infringement: Describe how the action is the least restrictive and least intrusive.

   • Public justification: Describe how the District Director of Health could offer public justification for the action on the basis of principles in the Code of Ethics or general public health principles, that citizens–in particular, those most affected–could find acceptable in principle. 

Sources

1. Bernheim, R. G., Nieburg, P., & Bonnie, R. J. (2009). Ethics and the practice of public health. In R. A. Goodman, R. E. Hoffman, W. Lopez, G. W. Matthews, M. Rothstein, & K. Foster (Eds.), Law in Public Health Practice, 2nd edition. Chapter 5.  Oxford: Oxford University Press. DOI: http://dx.doi.org/10.1093/acprof:oso/9780195301489.003.0005

2. Velasquez, M.l, et al. (2009). A Framework for Ethical Decision Making. Markkula Center for Applied Ethics. Santa Clara, CA: Santa Clara University Press.

10/17/2022  

• Updated policy header. 

• Verified active links.

• Updated titles of key contacts, as applicable.

• Updated Appendix D - Conflict of Interest Form pdf.

• Updated Appendix E - Ethics Advisory Committee Flowchart pdf.