Public health ethics related training for public health workforce: an emerging need in the United States.

BACKGROUND: Ethics is a discipline, which primarily deals with what is moral and immoral behavior. Public Health Ethics is translation of ethical theories and concepts into practice to address complex multidimensional public health problems. The primary purpose of this paper was to conduct a narrative literature review-addressing role of ethics in developing curriculum in programs and schools of public health, ethics-related instruction in schools and programs of public health and the role of ethics in developing a competent public health workforce.
METHODS: An open search of various health databases including Google scholar and Ebscohost yielded 15 articles related to use of ethics in public health practice or public health training and the salient features were reported.
RESULTS: Results indicated a variable amount of ethics' related training in schools and programs of public health along with public health practitioner training across the nation. Bioethics, medical ethics and public health ethics were found to be subspecialties' needing separate ethical frameworks to guide decision making.
CONCLUSIONS: Ethics based curricular and non-curricular training for emerging public health professionals from schools and programs of public health in the United States is extremely essential. In the current age of public health challenges faced in the United States and globally, to have an ethically untrained public health force is arguably, immoral and unethical and jeopardizes population health. There is an urgent need to develop innovative ethic based curriculums in academia as well as finding effective means to translate these curricular competencies into public health practice.

Introduction

What is Ethics? The Webster dictionary defines ‘ethics’ as discipline dealing with what is good and bad and with moral duty and obligation. It can also be defined as norms for conduct that distinguish between acceptable and unacceptable behavior or alternatively as a method, procedure, or perspective for deciding how to act and for analyzing complex problems and issues (1). This latter portion of the definition gets to the applied aspect of knowledge of ethics especially in dealing with complex public health problems and making a systems change.

There are diverse branches of ethics such as bioethics (implications of technology affecting human life), medical ethics (which primarily deals with patient-provider relationships and conduct of medical research involving human subjects), research ethics, and business ethics (2).

Why do we need ethics? Ethics is important to us because without it our actions would be random and aimless. We need ethics to organize our goals and actions and to accomplish our values. In essence, ethics evaluates those actions, and the values that underly them. It determines which values should be pursued, and which should not (3). The need for ethics arises from the fact that different professions have to establish a moral credibility for their field. In our field this needs to be translated into morally acceptable conduct and efforts to resolve ethical dilemmas related to public health practice (4). There are primarily five sources of ethical standards, which we use in practice including the utilitarian approach, the rights approach, the fairness or justice approach, the common good approach, and the virtue approach. When an ethical problem arises an integration of these approaches can assist in ethical-decision making (5).

The ethics field in health is governed by various codes of ethics such as principles of medical ethics (6), international code of ethics (7), Coalition of National Health Education Organizations code of ethics for health educators (8), Society for Public Health Education code of ethics (9) and the American Public Health Association code of ethics for public health (10). The purpose of having a variety of codes is to encompass the various health practitioners who practice individualized medicine as well as population level health.

The last decade has seen the evolution of public health ethics from a nascent effort of building a public health code of ethics (10) to a full-blown use of ethical principles and practices related to public health curriculum implementation (11), public health practice, and public health workforce development at the national level. Public health ethics, which was largely eclipsed by medical ethics (12) and bioethics fields in the past (13), has emerged as an important domain of public health practioners, health policy makers, and academicians. More and more public health professionals grapple with the issue of a delicate balance between individualistic civil liberties and the communitarian orientation-that is lessening the focus on individual rights and increasing the focus on communal responsibilities (14). Diverse ethical challenges are now becoming apparent. These arise from addressing public health issues related to health promotion, risk reduction, epidemiology and public health research and elimination of health disparities (15).

Ethical approaches can be placed into categories such as a) professional ethics (ethical principles and guidelines followed by a profession), b) Applied ethics (ethical conduct as applied to the real world), c) Advocacy ethics (advocacy for social goals and health reforms) and d) critical ethics (community involvement in discussions related to ethics in public health policy decisions) (15).

Public health ethics, by which we mean ethics applied to making well considered public health decisions when confronted with public health problems/issues and dilemmas typically faced by public health practitioners. Principles, which underlie the practice of public health ethics, are not restricted to the common ones such as beneficence, nonmaleficence, respect for autonomy and justice but also involve larger principles of connectedness, solidarity, and communal responsibility.

Should ethics continue to be taught in schools of public health and perhaps with a more emphasis? A survey conducted more than a decade ago to assess the amount of ethics instruction offered in schools of public health revealed that only 4% of the 24 schools surveyed required ethics instruction. Most of the schools (79%) offered short-courses, seminar series or invited lectures on ethical topics (16). There are series of debatable questions, which need to be considered if ethics need to be taught in schools and/or programs of public health.

Research has shown that teaching ethics in terms of theory does not necessarily translate into an ethical behavior in terms of public health practice (16). This knowledge –behavior gap is well known in health literature. Many questions remain unanswered such as, why and how do we teach ethics in schools and programs of public health? Is there a curriculum, which reaches out to a variety of target audience that enters the public health field? In an article by Coughlin (17) clear guidelines are drafted for ethics instruction in schools and programs of public health in terms of objectives to be attained, curricular goals to be reached and challenges to be addressed.

Hence, the primary purpose of this paper was to conduct a narrative literature review, which addressed: a) role of ethics in developing curriculum in programs and schools of public health, b) ethics-related instruction in schools and programs of public health and the role of ethics in developing a competent public health workforce.

Methodology

Search strategy:

A preliminary Google Internet open search on the terms, “Health and Ethics,” resulted in 36,000 articles/references. Upon further refinement, appropriate search terms were developed in line with the objectives of this study and searched in EBSCO Host databases and Scopus: “ethics and public health and workforce (28 results),” “ethics and public health and workforce and competencies (5 results),” & ethics and public health and competencies (28 results).”

Selection and inclusion/exclusion criteria:

From the above searches, articles related to public health and ethics, published between 2000 and 2011 were eligible for inclusion in the study. A total number of 15 articles met the inclusion criteria and were analyzed and salient findings reported. Seemingly, relevant articles that did not meet the inclusion criteria had to be excluded from analysis. In addition to the afore-mentioned exclusions, the following publications were excluded from this analysis: masters theses, doctoral dissertations, newspaper articles, and newsletters. Pease note that whereas articles on “Medical Ethics” are important and critical to our understanding of the development of ethics in professional practice; the focus of this paper is on “Public Health and Ethics.” Thus, any articles that only reference “Ethics in Medicine,” were not eligible for inclusion in this analysis. However, seminal articles whose omission would detract from the effectiveness of the proposed analysis were included in this review, such as papers referenced in numerous public health articles.

Results

Some of the relevant focus areas quite evident from this review stated the importance of a) redefining ethics and its applications in the realm of public health settings as opposed to biomedical settings, b) public health interventions versus public health research and c) application of ethical principles and philosophical theories to complex public health problems (18). As public health ethics emerges as a distinct field from bioethics or medical ethics, public health practitioners will continuously struggle to apply theories, principles, and values across a myriad of community and public health issues.

Health equity is a central tenet of population based health especially when conducting ethical research among socio-economically vulnerable and racially and ethnically minority populations (19). The role of ethics in a feminist approach adds an important dimension to population-based research, especially when addressing a global public health ethics agenda (20).

Finally, in a quest to maintain an intricate balance between individual and community based research, community advisory boards play a crucial role in protecting communities by way of community consultation (21). A thin line exists between public health research and public health practice. Although ‘utilitarianism’ is the primary underlying principle in research based ethics applications, there is still an ongoing need of establishing ‘public health ethics’ as an independent field to reckon with (22).

The authors further sought to analyze ethics related training received by the emerging professionals from schools and programs of public health in addition to ethical competencies developed for practicing public health professionals.

Table 1 shows ethics related training received by public health professionals in academia and practice (Academic Competencies as mentioned by the Association of Schools of Public Health & Non-Academic Competencies by the Council of Linkages).

Table 1:

Ethics related training in Competency and Learning Outcome Models/Projects *(43)

Models/Projects	Essential Features	Ethics related training
1. Council on Linkages between academia and public health practice	Core competencies for public health professionals- Tiers 1 –Tier2-Tier 3	Ethical principles applied to assessment skills Ethical principles mentioned as a part of expected outcomes of policy options. Ethical conduct of research for developing public health sciences skills.
	Competency areas:a) Analytical/Assessment skills/b) Policy development/program planning skills/c) Communication skills/d) Cultural competency skills/e) Community dimensions of practice skills/f) Public Health Sciences Skills/g) Financial Planning and Management Skills/h) Leadership and systems thinking skills
2. Public Health Preparedness & Response-Core Competency Model	Core competency areas:a) Foundational public health competencies (Core competencies for public health professionals & ASPH Master’s degree in Public Health Core competencies./ b) Emergency core competencies/c) Position specific or professional competencies/Other competency areas:/ a) Model Leadership/b) Communicate and Manage information/c) Plan for and improve practice/d) Protect worker health & safety	a) Some ethical principles applied as a part of competencies for public health professionals.
3. Master’s Degree in Public Health Core Competency Model – Version 2.3	Discipline specific competenciesa) Biostatistics/b) Environmental Health Sciences/c) Epidemiology/d) Heath Policy and Management/e) Social and Behavioral Sciences	a) Emphasizes importance of epidemiology for ethical discussion of health issues/b) Emphasizes ethical basis for public health and health services/c) Emphasizes ethical principles to public health program planning, implementation and evaluation./ d) Emphasizes application of ethical principles for use of information technology and resources in public health settings./ e) Emphasizes role of professional ethics and practices in diverse community settings./ f) Identification of ethical issues implied by public health biology/g) Emphasizes application of ethical principles
	Interdisciplinary/Cross-cutting competenciesa) Communication and Informatics/b) Diversity and Culture/c) Leadership/d) Public Health Biology/e) Professionalism/f) Program Planning/g) Systems thinking
4. DrPH Core competency Model	Core competency areas:a) Advocacy/b) Communication/c) Community/Cultural Orientation/d) Critical analysis/e) Leadership/f) Management/g) Professionalism & ethics	Competency of Professionalism and Ethics comprehensively addresses issues of managing conflicts of interests, strategies for resolving ethical concerns, ethical concerns in communication and cultural sensitivity in ethical discourse/analysis.
5. Global Health Competency Model Version 1	Competency domainsa) Capacity Strengthening/b) Collaborating and Partnering/c) Ethical Reasoning and Professional Practice/d) Health Equity and Social Justice/e) Program Management/f) Socio-cultural and political awareness/g) Strategic analysis	Ethical reasoning and Professional practice addresses competency based ethical training.
6. Undergraduate Public Health Learning Outcomes Model version 1	Domains:a) Domain 1- knowledge of human cultures and the physical and natural world as it relates to individual and population health./ b) Domain 2- intellectual and practical skills./ c) Domain 3- personal and social responsibility. /d) Domain 4- integrative and applied learning	Emphasizes analyzing ethical concerns and conflicts of interest which arise in the field of public health in Domain 3.
7. Cultural competence education for students in medicine and public health	Competency in 3 domains:a) knowledge/b) skills/c) practices	No specific mention of ethical training or application.
8. Interprofessional Education project	Team-based competenciesa) Values /Ethics for interprofessional practice/b) Roles and responsibilities for collaborative practice/c) Interprofessional communication./ d) interprofessional teamwork and team-based care	Ethical applications are clearly mentioned as a competency area of education.

Association of schools of public health-Competency and Learning Outcomes development project

Discussion and Conclusions

This paper addressed use of ethical theories and principles from the point of training an emerging cadre of new public health professionals. The other significant aspect of this paper was to emphasize the importance of identifying and developing strategies for maintaining ethics-based instruction in not only schools and programs of public health but also via distance learning training programs, webinars, and workshops for public health practitioners in diverse employment settings.

Attempts conducted in past by organizations and associations such as the Council on Education on Public Health (CEPH), the National Institute of Health (NIH) and the Association of Schools of Public Health (ASPH) in forging value-based training and ethical conductance of research have been commendable but still little is known about the details of the actual training in terms of quantification (23–25). Furthermore the data obtained in the past, has severe limitations as medical schools –related ethics training was not included in the analyses. Ethics training as a part of medical education shows great variability in terms of content, timing, and form. (26, 27).This is crucial as medical schools do produce a limited but important addition of public health professionals (28, 29).

In an era where public health workforce training (30, 31) is advancing towards competency-based academic curricular (32, 33) and competency-based public health practice training (34–36), it is unclear (from this current review of articles) how much of training related to ethics is received in academic-based programs or practice-based settings. There are limited curricular opportunities and practice-based opportunities for ethics training.

Academicians and public health practitioners need to question the need of a value-based training, which provides sufficient scientific integrity in addressing complex public health problems. Coughlin (17) addresses innovative development of ethics-based curriculums by paying close attention to areas such as a) objectives and goals to be attained by a training institution or an organization, curriculum designing (taking into account student needs, problem-based learning and balancing these with content expertise of the trainers), establishing a practical framework and lastly anticipating and addressing current and future challenges as they arise (17).

Why does this matter? Curricular and extracurricular didactic training may not necessarily improve the moral character of an individual but will certainly facilitate him/her to translate its principles in their fieldwork or practice-based settings. Ethics of relying on a non-competent and untrained public health workforce needs to be questioned. In the current age of public health challenges faced nationally and globally, to have an ethically untrained public health force is arguably, immoral and unethical. Furthermore whether this workforce, follows any ethical standards or practice is unclear.

Recommendations for Public Health Practioners

Academic competencies: Ethics training should be an integral component that is incorporated into the curriculum of programs and schools of public health. This training should be substantiated by the ethical practices modeled in the research and academic units of programs and schools of public health. Whether this training should be incorporated by a bioethics trained professional or by a public health professional with advanced level training related to ethics is a matter of concern and debate.

Ethical Competencies in Public Health Practice: National Level Certification examinations (for example, Certified Health Education Specialist (37), Masters Certified Health Education Specialist (38), Certified in Public Health (39)) and various public health conferences should possibly offer continuing education credits specifically for ethics-related training. This initiative of addressing ethics related training or ethical competency based training can be extended to health education and public health organizations at the federal, state and local levels as well.

Lastly, a question, which needs to be answered, is whether there are going to be ethical challenges associated with implementation of the 2010 Affordable Care Act (40, 41)? If so, then how can we ensure public health practitioner preparation for such contingencies, corollaries, and components associated with the new Affordable Care Act that expands health care access for previously disenfranchised population subgroups?

Ethical considerations

Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc) have been completely observed by the authors.