Ethical Decision-Making in Global Public Health: Using the Public Health Ethical Reflection Tool

Background: Decision-makers in global public health face significant ethical dilemmas in the setting of uncertainty, resource scarcity, urgency and exceptional complexity. The challenges encountered are often at the intersection of clinical ethics, research ethics, and public health ethics with superimposed political, economic and cultural factors. To date, there are few widely used prescriptive frameworks for global public health, and little is known about public health practitioners ethical perspectives.

Objectives: 1. To develop a framework for global public health ethics that is flexible, justifiable, straightforward, capable of being applied to diverse ethical challenges, and is free from the presumption of a common value system. 2. To gather data on the ethical and meta-ethical positions of public health practitioners, and the dilemmas they face in practice.  

Method: The Public Health Ethical Reflection Tool (PHERT) was developed by integrating concepts from the public health, medical and philosophy literature into a simplified matrix. A survey tool was constructed based on this conceptual framework and distributed via a web-based survey to Canadian and American public health practitioners, trainees, nurses and inspectors. Qualitative data was coded into open themes. Quantitative data was analysed using SPSS 15. The data was fed back to participants during 1-3hr educational workshops. 

Results: The PHERT Matrix was developed, populated, and applied to a range of ethical dilemmas. Canadian (n=75) and American (n=508) public health physicians, trainees (n=27), public health nurses (n=51) and public health inspectors (n=531) responded to the survey. There was remarkable heterogeneity of responses regarding prioritization of values, meta-ethical justification of ethical norms, and dilemmas faced. 

Conclusions: A variety of disparate ethical perspectives are held by public health practitioners. The PHERT framework is a potentially helpful tool for use by individual decision makers, groups or organizations for the identification, organization and resolution of ethical dilemmas in global public health.