Ethical Considerations�in Decision Making �for Public Health Interventions

Brogen S Akoijam

Dean, RIMS Imphal

Courtesy: John Travis, 1972

DEATH

HIGH LEVEL WELLNESS

PUBLIC HEALTH INTERVENTIONS

NO SIGN/SYMPTOMS

Evidence

Benefits? Harms?

Individual liberty

Privacy

Confidentiality

Choice

Alternative?

For whom?

Decisions: Why? Who? What? How?

>Individual Responsibility

Public involvement

Decision Making in Health Care: Premises

• Decision making in health care, at large, has been a complex exercise
• Lack of strong evidence
• Lack of transparency, accountability & procedural clarity
• Conflicts of interests – social, ethics, legal, economic, political, etc.
• Akin to HTA – science + society/economics/ethics + procedure
• Ethical principles & values are, pragmatically, contextual
• Different sectors have proposed various frameworks – GRADE EtD, WHO-Integrate, A4R, etc.

​

A4R

Ethical framework that describes conditions of a fair decision-making process

Five

Components ?

Empowerment

Transparency/Publicity

Revision/ Appeals

Compliance/ Enforcement

Relevance

Empowerment

• Facilitate effective participation of all affected stakeholders
• Provide training & support for staff

Empowerment

Transparency/Publicity

Revision/ Appeals

Compliance/ Enforcement

Relevance

• Formal communications plan to support decision-making:
• Why decisions must be made?
• How decisions will be made?
• Who will make decisions?
• Which criteria will be used?
• Publicize decision & its rationale

Transparency/Publicity

Empowerment

Transparency/Publicity

Revision/ Appeals

Compliance/ Enforcement

Relevance

Revision/ Appeals

Revise & revisit decisions through formal appeals or through consultation with stakeholders:

• New evidence/ Arguments brought forward
• Mechanism for challenge & dispute resolution

Empowerment

Transparency/Publicity

Revision/ Appeals

Compliance/ Enforcement

Relevance

• Clarify aims & scope of priority setting process
• Identify explicit decision criteria
• Clear articulation on ‘Organizational Ethics’ to different stakeholders about:
• Mission
• Vision
• Policy statement

Relevance

Empowerment

Transparency/Publicity

Revision/ Appeals

Compliance

Relevance

• Lead by example, commit to the laid down procedure
• Formal evaluation strategy to improve the decision making process

Compliance/ Enforcement

Empowerment

Transparency/Publicity

Revision/ Appeals

Relevance

Compliance/ Enforcement

A4R

Empowerment

Transparency/Publicity

Revision/ Appeals

Compliance

Relevance

Driven by Science & Evidence

Driven by ‘multiple factors:

• Economic
• Ideological
• Personal

Sustained, constructive engagement between public health & political systems required

COVID-19

Credibility in evidence: Scientific debate

&

Fair criteria for scare resource allocation with considerations of reducing collateral damage:

• Compensation for those not meeting the criteria but entitled to care
• Those needing urgent treatment for other diseases

Effective A4R?

Ethical Values of A4R

• Accountability
• Inclusiveness
• Openness & Transparency
• Reasonableness
• Responsiveness

BENEFICENCE

Weigh familial & self obligations with their professional duty to care

JUSTICE

All persons have an equal claim to receive needed interventions

JUSTICE

Support those facing disproportionate burden in protecting public good

NON-MALEFICENCE

• Disclose only relevant information to achieve legitimate public health goals
• Only if there are no less intrusive means
• Intended good is significant enough against potential harm from suspending privacy rights

Requires that restrictions to individual liberty to protect public from harm should not exceed what is necessary to address actual level of risk

NON MALEFICENCE

• Weigh medical & moral imperative
• Ensure stakeholders are aware of benefits & consequences
• Mechanisms to review decisions

AUTONOMY

Restrictions to individual liberty should:

• Be proportional to risk of public harm
• Be necessary & relevant
• Employ least restrictive means
• Be applied without discrimination

COVID-19 heightened global awareness of need of solidarity within & across systems

Both institutions & individuals will be entrusted with governance over scarce resources

Build trust before crises hits not while it is in full swing

Summary

• Decision making in public health intervention
• Searching and agreeing on evidence
• Defining the ethical values and addressing the conflicts in the light of social, economic, legal and political milieu
• Adopting a fair, transparent and accountable procedure

1. Joint Centre for Bioethics. Ethical decision-making about scarce resources: A guide for managers and governors. Canada: University of Toronto; 2019. 9 p.
2. Thompson, AK, Faith K, Gibson JL. Pandemic influenza preparedness: an ethical framework to guide decision-making. BMC Med Ethics. 2006 Dec 4;7(12):1-12. https://doi.org/10.1186/1472-6939-7-12.
3. Gibson JL, Martin DK, Singer PA. Evidence, economics and ethics: resource allocation in health services organizations. Healthc Q. 2005;8(2):50-9. doi:10.12927/hcq..17099.
4. Baeuchamp TL, Childress JF. Principles of Biomedical Ethics. 6^th ed. USA: OUP USA; 2008. 432 p.

Thank You