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Advocating for Public Health Policy[WLO: 3] [CLOs: 1, 5]Prior to beginning work on this discussion, read Chapter 8 in your textbook, and review Chapter 5 sections on policy. Read the Stop the Global Epidemic of Chronic Disease: A Practical Guide to Successful Advocacy. Links to an external site.Review the Policy Statements and Advocacy Links to an external site.web page and How to Write a Health Policy Brief. Finally, review the grading rubric for grading criteria.Imagine that you have been chosen to represent a public health advocacy group as they begin a campaign to get legislation related to a health issue passed in your state legislature. You have been tasked with the role of presenting a proposed policy to the legislature and advocating that the legislature vote for the policy. You have been told that you will have 10 minutes to present to the legislature.For this assignment, you will create an 8 to 10-minute presentation. Your presentation should be informative, but also persuasive, and be absolutely no longer than 10 minutes but no less than 8 minutes. Your presentation can be created using Screencast-O-MaticLinks to an external site., the camera and microphone on your computer or handheld device within Canvas, or you can create slides using the voice recording functions within a presentation program (like PowerPoint). Instructions on how to use these tools are below. Professional dress, attitude, and clear communication matters for this assignment. The legislature will need to make a decision about whether or not to vote for the policy based on your presentation. Your presentation should be structured exactly as if you were “live” in front of the legislature advocating for them to adopt the policy you are proposing.For your presentation, you will need to select a public health topic of interest to you (you are encouraged to choose one related to your academic major or intended field of work) and a public health policy related to addressing the topic. You may select an actual proposed policy or create one that you think would effectively address the topic. Your presentation should provide enough information about the topic and the proposed policy that a reasonably educated legislator should be able to make an informed decision. Be sure to consider the various questions that a legislator might have about the issue and proposed policy, such as long-term costs and benefits, potential effects on business and industry (especially those that support politicians’ campaigns), and how the policy will support the health and productivity of state residents.Your presentation should address each of the following points:Discuss the public health issue that your proposed policy is intended to address. Questions to consider:Who does this health issue affect?What is the impact of this health issue on the community?Why does this health issue need to be addressed?Explain the proposed public health policy. Questions to consider:Who will be affected by this policy?How will this policy address the health issue?What will change by enacting this policy?Evaluate the impacts of the proposed policy. Questions to consider:What are the costs and benefits of the policy?What are the risks of enacting or not enacting the policy?How will the lives of people who are affected by the health issue change if this policy is enacted?Create an influential presentation that affects voting behaviors of legislators. Questions to consider:What information about this policy would potentially affect the voting behavior of legislators from across the political spectrum (e.g. conservative, moderate, liberal, progressive; particularly those who might not support the policy based on political orientation)?What are the most important messages that legislators need to hear about this policy?How would the constituents of the legislators voting for this policy feel about this policy and a legislator who votes for it?What information would a legislator need to “sell” the policy to constituents who were perhaps not in favor of adopting the policy?The Advocating for Public Health Policy assignmentMust be 8 to 10-minute formal presentation recorded as a video, screencast, or using the voice recording functions in a presentation program.Must include at least 100 words in the presenter’s notes for each slide if choosing a presentation program.You may want to look at How to Make a PowerPoint PresentationLinks to an external site. to get started. Pay attention to APA style and formatting in this “how to” guide. APA guidelines are required in presentations and any scholarly work you create.Must include a separate title slide with the following:Title of presentationStudents nameCourse name and numberInstructor’s nameDate submittedMust utilize academic voice. See the Academic VoiceLinks to an external site.resource for additional guidance.Must include an introduction and conclusion statement. Your introduction needs to end with a clear statement that indicates the purpose of your presentation.For assistance on writing Introductions & ConclusionsLinks to an external site.refer to the Ashford Writing Center resources.Must use at least three scholarly, peer-reviewed, or credible sources (one of those may be the course text).The Scholarly, Peer Reviewed, and Other Credible SourcesLinks to an external site. table offers additional guidance on appropriate source types. The Ashford University Library is a great place to find resources. Watch the Ashford University Library Quick ‘n’ DirtyLinks to an external site. tutorial for research tips. If you have questions about whether a specific source is appropriate for this assignment, please contact your instructor. Your instructor has the final say about the appropriateness of a specific source for a particular assignment.Must document any information used from sources in APA style as outlined in the Ashford Writing Center’s Citing Within Your Paper.Links to an external site.Must include a separate reference slide or reference page that is formatted according to APA style as outlined in the Ashford Writing Center. See the Formatting Your References ListLinks to an external site. resource in the Ashford Writing Center for specifications.Must use speakers notes as follows:Review the PowerPoint Speaker NotesLinks to an external site. video tutorial. (YouTube Accessibility StatementLinks to an external site. and Privacy PolicyLinks to an external site.)Speaker notes are the typed notes that appear below the slide that complement the presentation slides. Whereas the slides will have short bulleted items, the speaker notes will be more detailed. They are essentially what the presenter would say during the presentation to explain each of the bulleted points on the slide. Therefore, it is important that the speaker notes are concise and detailed when explaining the bullet points.It is recommended that PowerPoint Slides contain no more than five bullet points and should not contain more than seven to 10 words each. Do not type paragraphs or long sentences on the slide. The information that explains each bullet point is conveyed via speaker notes or by recording your voice to each slide.If you are unable to access the technology for this assignment due to a documented accommodation on file with the Office of Student Access and Wellness, inform your instructor as soon as possible.Creating Your Presentation:Choose one of the following options to create your presentation:Option 1: Use the native video tool in your classroom.If you choose this option, you will record and upload your media in the Week Four Assignment Presentation page. Choose the Week Four Assignment Presentation button below to get started. Option 2: Use Screencast-O-Matic.Links to an external site. Please review the instructions provided by Screencast-O-Matic Quick-Start GuideLinks to an external site. in order to get started. This guide will familiarize you with the tool and review how to upload your video to the classroom. If you choose to use another video recording tool for your submission, please follow the guide instructions to upload an MP4 video file into your classroom using the same steps.Option 3: Create a presentation using the voice recording functions within a program like PowerPoint.Review the Ashford Writing Center’s Presentation TipsLinks to an external site. and Don McMillan: Life after death by PowerPointLinks to an external site. to assist you with creating the presentation.Submitting Your Presentation:Follow these steps to submit your presentation and speaker’s notes:Step 1:Submit your full presentation as a video (.mp4, .mpg, etc.), PowerPoint (.ppt or .pptx) or other presentation type in the Week Four Assignment Presentation page using the button below.Week 4 Assignment PresentationStep 2:Submit your speaker’s notes as a PDF or Word document to Waypoint using the Waypoint Assignment submission button at the bottom of this page.For additional guidance, review the File Submission Quick Start Guide.Carefully review the Grading RubricLinks to an external site. for the criteria that will be used to evaluate your assignment.
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5
Public Health Ethics, Law,
and Policy
benkrut/iStock/Thinkstock
Learning Outcomes
After reading this chapter, you should be able to
• Explain the relationship between ethics and public health work.
• List the central assumptions of the Public Health Code of Ethics.
• Summarize the importance of key public health cases.
• Illustrate how policies and laws are utilized in public health efforts.
© 2019 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution.
The Role of Ethics in Public Health
Section 5.1
The ethics, morals, laws, policies, and legislation involved in public health can become very
confusing, even for those who work in the field. This chapter provides a brief overview of each
of these elements, plus examples of their importance and function in the public health realm.
In public health, it is important to understand and differentiate between terms such as ethics
and morals, as they can be vastly different in practice. The Public Health Leadership Society’s
principles of ethical practice are also key to understanding how and why public health officials make policy recommendations.
Lastly, this chapter discusses the difference between policy and law, focusing on how policy
shapes public health, including its responsibilities and its outcomes. The role of policy briefs,
their purpose, and how they are written is explored, and examples of existing policies that
became laws and how they have worked within the public health realm are summarized.
5.1 The Role of Ethics in Public Health
Morals and ethics are very much alike in many respects, and the terms are often used interchangeably; however, they are not the same concepts. Morals are an individual’s principles of
right and wrong. They set the stage for acceptable behaviors and beliefs. Morals are not universal, and they are highly individualized, often shaped by upbringing and culture. A person
living in House A on Street A may believe that elbows on the table during dinner is unacceptable (it is “wrong,” or immoral), while a person living in House B on Street B may believe that
elbows on the table at meal time is fine (it is “right,” or moral).
Ethics are principles that govern a person’s behavior because they are rules provided by an
external source, such as codes of conduct in a community setting or a workplace. Ethics are
more universal and common to a set community. For example, the community of residents on
Street B are Amish, and those on Street A are not
Amish. The community ethical code in the Amish
community (everyone on Street B) would state
that elbows on the table are unethical behaviors.
This is now considered a principle governed by an
external source (the Amish community). So, while
the person living in House B on Street B may have
a moral belief that elbows on the table are fine, the
community of Street B says it is unethical. This is
where ethics and morals can collide. In most situations, the ethics of the community outweigh the
Ridofranz/iStock/Thinkstock
morals of the individual.
Personal and cultural beliefs about
allowing terminally ill or dying
patients to refuse treatment or request
physician-assisted suicide may conflict
with laws.
In public health, morals and ethics collide frequently in decision-making. Vaccinations against
certain diseases are good examples of this collision. For instance, the state of Pennsylvania might
represent the community and mandate vaccination. In this case, Pennsylvania is the external
source that sets the code of conduct—the ethical standards for those who live in the state. But
there may be many individuals in the state who personally disagree with this code and refuse
vaccination. The individuals’ moral beliefs collide with the overarching community’s code.
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The Role of Ethics in Public Health
Section 5.1
Who wins? Who is right? If the law intervenes, it will usually be the community ethical standards that will be upheld; however, if there are no laws, the individual’s morals may stand.
A national law states that all children must receive vaccinations before attending school. In
this case, if an individual is opposed to vaccination yet has a child who needs to attend school,
the individual must abide by the law in order to send the child to school.
As noted in the vaccination example, laws do not always agree with every single community’s
morals, but the laws are established to protect that society as a whole. In many cases, laws
truly conflict with ethics and morals. For example, it is illegal to kill another human being,
even in cases of physician-assisted suicide for dying, or terminal, patients. However, some
cultures and individuals believe that it is ethical to allow a person to die with dignity rather
than live in pain. Individually, people may believe that physician-assisted suicide is also right.
In this case, ethics and morals are similar, but the law prohibits the intended action.
Research and Clinical Ethics
The idea that ethics plays a role in public health is relatively new. More widely understood are
the concepts of research ethics and clinical ethics. Research ethics involves the protections
of human subjects who are taking part in a study. This usually includes a plethora of disclosures and permissions. Most people won’t encounter the concept of research ethics unless
they are part of a research project.
Clinical ethics is more commonly understood because it is encountered in doctor’s offices,
clinics, hospitals, and all health-related organizations and facilities. Clinical ethics addresses
issues that arise within the patient care realm. Privacy and confidentiality of the patient are
the most common ethical practices in the clinical setting, the importance of which contributed to the law known as the Health Insurance Portability and Accountability Act of 1996
(HIPAA). This law requires the protection and safeguarding of all personal health information.
Ethically, it seems obvious that health information should be private, and many offices had
already been keeping it private before the law was passed because it was valued as important.
Making it law transformed this ethical practice into a legal requirement.
Public health is quite different from clinical health, and, therefore, the focus areas of ethics in
both arenas are different. Clinical ethics is related to the treatment of disease and injury, while
public health ethics is important in the prevention of disease and injury. Table 5.1 shows a
comparison of the two.
The terms principles and values appear frequently in this chapter, and both play a key role in
the ethical practice of public health. However, whose principles and values are being considered? While all people have values of some sort, public health values are rooted in science and
community in an effort to prevent disease and injury, protect the public from harm, and promote health and well-being (Barrett et al., 2016). Public health professionals do not use their
morals when making decisions that will affect the public. Public health values rest on two
ideas: that most health interventions rely upon the community’s acceptance, cooperation,
and participation to be successful, and that public health must gain a community’s trust to be
able to function effectively. These are the guiding values of public health and the basis for all
actions that public health professionals perform at the local, state, federal, and global levels.
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The Role of Ethics in Public Health
Section 5.1
Table 5.1: Comparison between clinical and public health ethics
Clinical ethics
Public health ethics
Medical interventions by clinical professionals
Range of interventions by various professionals
Seeks to avoid harm based on the provider’s
fiduciary relation to the patient
Seeks to avoid harm based on collective action
Individual benefit
Respect for individual patients
Professional duty for patients over provider
Based on trustworthiness of physician and medical
profession
Informed consent from individual
Limited to treating patients equally and ensuring
universal access to health care
Social, community, or population benefit
Relational autonomy of interdependent citizens
(community)
Duty to community over individual
Based on law
Community consent through consensus
Concern with social justice regarding health and
achieving health equity
Source: Adapted from “Public Health Ethics: Global Cases, Practice, and Context,” by L. W. Ortmann, D. H. Barrett, C. Saenz, R. G.
Bernheim, A. Dawson, J. A. Valentine, and A. Reis, in D. H. Barrett, L. W. Ortmann, A. Dawson, C. Saenz, A. Reis, and G. Bolan (Eds.),
Public Health Ethics: Cases Spanning the Globe (Vol. 3, p. 23), 2016, Geneva, Switzerland: Springer International Publishing,
Open Access.
Ethics and Public Health Decision-Making
In all public health activities, principles and values provide the framework and justification
for decision-making. In essence, every aspect of public health must adhere to an ethical framework. The CDC (2017w) follows three core functions when applying an ethical framework to
its activities:
1. Identify and clarify the ethical dilemma.
2. Analyze the dilemma in terms of alternative courses of actions plus whatever resulting consequences may occur.
3. Resolve the dilemma through decision-making that incorporates and balances the
guiding principles and values.
This framework comes with several key questions to help public health professionals walk
through the process to determine the next steps.
Core Function 1: Identifying and Clarifying the Ethical Dilemma
When examining a potential intervention in public health, the first step is to provide the foundation on which to base the decision. These questions are usually discussed at length:
• What are the risks, harms, and/or concerns?
• What are the public health goals?
• What is the scope of legal authority? That is, what laws and regulations may or may
not apply?
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The Role of Ethics in Public Health
Section 5.1
• What are the moral norms of the community?
• Are there any similar cases that provide legal or ethical guidance?
Consider the potential issues of requiring motorcyclists to wear helmets. In this situation,
public health officials have to analyze the risks to, and concerns of, the rider as well as those
who may be affected, such as the rider’s family, those who pay for the medical services and
costs, and other people on the road. The ethical dilemma is “What harm would come if helmets were required for all motorcyclists?”
This function of the framework also examines community norms. Is there a social concern
with motorcyclists not wearing helmets across the state? Is there a strong advocacy call for
helmet use? What economic issues would result if helmets were required? Obviously, there
is the cost of the helmet, but there is also the cost of medical care in the event an accident
occurs. Some people in opposition to the helmet laws state that it violates their personal
rights to make their own choices. Supporters of the laws claim that those who get into accidents and succumb to head trauma drain medical resources—especially those who do not
have insurance. It is an injury that can be prevented just by wearing a helmet.
States’ opinions on the helmet law vary based on the answers to these questions. Some have
no laws or require only passengers under age 17 to wear a helmet; others require everyone
on a motorcycle to wear one (Insurance Institute for Highway Safety, 2018). The state of New
York requires the use of helmets and has since 1967 (Insurance Institute for Highway Safety,
2018). Refer to A Closer Look for another example of a state examining an ethical dilemma in
public health.
A Closer Look: Applying the Ethical Framework to Alaska
Smoking Laws
While Alaska has one of the most lenient
smoking laws in the United States, smoking is
prohibited in schools, childcare facilities, most
health care facilities, and elevators (American
Lung Association, 2016). However, the
state government has left the door open for
communities to take matters into their own
hands, which includes establishing stricter
regulations if they wish to do so.
While public health professionals view the
ban as a lifesaving measure, others see it as
an attack on personal rights. This is an ethical
dilemma that the state cautiously addressed
by leaving the main decisions in the hands of
each municipality. The state law takes into
consideration the rights of smokers by not
banning the practice under one law.
Stefan Malloch/iStock/Thinkstock
Alaska has one of the most lenient
smoking laws in the United States.
Communities can apply stricter
regulations if they wish to but are not
required to do so.
(continued)
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The Role of Ethics in Public Health
Section 5.1
A Closer Look: Applying the Ethical Framework to Alaska
Smoking Laws (continued)
The compromise was simple: If a community desires to allow smoking, it must designate
specific locations and clearly mark them with signage. This is to protect the health of those
who do not wish to inhale secondhand smoke, as the law states that everyone has the right to
clean air. The signage is helpful, but some municipalities did desire to go beyond the state’s
law. As a result, some major cities and smaller towns adopted stronger policies based on
residents’ desires (see Core Function 1 of the ethical decision-making framework):




Sitka, November 18, 2005: Banned smoking in all enclosed workplaces, including
restaurants but exempting bars
Anchorage, July 1, 2007: Banned smoking in all workplaces, bars, and restaurants
Juneau, January 2, 2008: Banned smoking in bars and restaurants (but not other
workplaces)
Nome, September 20, 2011: Banned smoking in bars, restaurants, outdoor stadiums,
vehicles when used for public transportation, and all enclosed workplaces
Only 11 cities in the state of Alaska have adopted completely smoke-free workplaces:
Anchorage, Bethel, Haines, Juneau, Klawock, Nome, Palmer, Petersburg, Skagway, Unalaska,
and Valdez. Most of the cities and towns in Alaska abide by the signage law imposed by the
state.
Sources: American Lung Association. (2016). SLATI state information: Alaska. Retrieved from http://www.lungusa2.org/slati
/statedetail.php?stateId=02
State of Alaska. (2017). Alaska smoking law. Retrieved from http://dec.alaska.gov/eh/fss/Smoking_Home.html
Core Function 2: Analyzing the Dilemma
This function revolves around options. Three key points are considered:
• What are the short- and long-term options given the responses to the questions from
Core Function 1?
• What are the ethical concerns of each option?
• Are there other considerations that should be reviewed, such as privacy, commitments, or transparency?
One such public health dilemma received considerable attention and review at this step of
the ethical framework: bicycle helmet usage. In the early 1970s, the issue gained momentum in Australia, where a significant number of bicyclists died from head injuries. The Royal
Australian College of Surgeons actively campaigned to raise awareness of head injuries and
their prevention through the use of helmets. Shortly after the campaign went into effect, Australia became the first country to require helmets for bicyclists, in the early 1990s (Rachele,
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The Role of Ethics in Public Health
Section 5.1
Badland, & Rissel, 2017). New Zealand followed suit in 1994. Deaths and head injuries from
bicycle riding began to drop due to helmet use, and the word was spreading into other countries. In 1987, the United States began to adopt helmet laws at the state level; however, there
was pushback from adults (Helmets.org, 2017). Most people agree that protecting children
under age 18 is important. Therefore, laws that focused on children and youth helmet use
were mostly welcomed.
Today in the United States, there are no federal laws
requiring bicycle helmet use by anyone riding a bicycle. Twenty-two states require helmet use, typically
for children, and more than 200 localities (municipalities, cities, etc.) maintain local ordinances on
the issue (Helmets.org, 2017). For example, Kansas
does not have a statewide law requiring helmet use
while riding a bicycle, but the city of Lawrence, Kansas, requires all children and youth under age 16 to
be helmeted (Helmets.org, 2017). There is no law
in any state that requires adults to wear a helmet
(Insurance Institute for Highway Safety, 2017b).
According to Nicaj et al. (2006), 97% of bicyclists
who died in an accident in New York City from 1996
to 2005 were not wearing a helmet.
LydiaGoolia/iStock/Thinkstock
There are no federal laws that require
helmet use for anyone riding a bicycle,
but about half of the states have laws
that require helmet use, typically
for children.
Bicycle helmet use remains a significant ethical
dilemma for communities. When addressing the
questions in Core Function 2, the local municipalities were given the authority to determine whether
a bicycle helmet law would invade their residents’
rights, privacy, and way of life. Public health lost the
battle to have an overarching law on helmet use, as
regulations more often focus on the protection of
children rather than the entire population of bicycle
riders. Advocacy groups are still working toward a
federal law requiring all bicyclists to don a helmet.
Core Function 3: Resolving and Justifying the Decision
Decisions in the public health realm are not random. They require solid justification by taking
into consideration all aspects and opposition. Public health officials ask five key questions
when justifying decisions (Table 5.2). One important aspect related to the practice of public
health is to ensure that the values of the community do not clash with the values of the public
health intervention. After all steps are reviewed and options considered, the decision makers must be able to address the five factors and their associated questions in full to adopt an
intervention, law, or policy.
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The Role of Ethics in Public Health
Section 5.1
Table 5.2: Justification for public health decisions
Factor
Key questions
Effectiveness
Is the action going to be effective? Will it make a difference in terms of the overall
goal(s)?
Necessity
Is this intervention truly needed to achieve the goal(s)?
Proportionality
Will the benefits outweigh the infringement on the community’s individual values,
principles, and morals?
Least infringement
Will this intervention cause the least disruption and upheaval of the community’s
values, principles, and morals?
Public justification
Is there solid evidence to justify this decision that most people will find acceptable?
Source: Adapted from “Public Health Ethics: Global Cases, Practice, and Context,” by L. W. Ortmann, D. H. Barrett, C. Saenz, R. G.
Bernheim, A. Dawson, J. A. Valentine, and A. Reis, in D. H. Barrett, L. W. Ortmann, A. Dawson, C. Saenz, A. Reis, and G. Bolan (Eds.),
Public Health Ethics: Cases Spanning the Globe (Vol. 3, p. 29), 2016, Geneva, Switzerland: Springer International Publishing,
Open Access.
For example, not all states have adopted helmet laws for motorcyclists because those five key
elements could not fully address all residents’ questions. The biggest element fell under “least
infringement,” where people felt this law was a violatio …
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