A study of day-to-day ethical issues in public health practice in Michigan

Background: Academics have begun to distinguish between the ethical challenges that arise in clinical medicine and those in public health practice. Yet little data exists about the types of ethical issues public health practitioners face in their daily work.

Methods: To ascertain the ethical issues practitioners encountered and the resources they used to resolve them, we conducted 45 semi-structured interviews with public health practitioners across a range of occupations (e.g., health officers, medical directors, sanitarians, nurses) at 13 health departments across Michigan.

Findings: Each respondent identified multiple ethical challenges and described underlying values that motivated their actions. While the ethical issues respondents cited were diverse, common broad categories included: using the public health authority to protect health while balancing the community's economic viability or individuals' autonomy; allocating limited resources to meet community needs; and negotiating tensions emerging from political oversight of public health practice. The political tensions included negotiating pressures to allow non-compliance with environmental health regulations, providing services within rigid funding structures or mandates, and balancing politically-identified priorities with practitioners' perceptions of the community's health needs.

In resolving ethical considerations, respondents cited their own underlying values, including helping the most vulnerable, fairness, consistency, and evidence-based actions. Practitioners also relied on consultations with colleagues to resolve ethical challenges, infrequently using frameworks or ethical codes for decision-making.

Conclusions: Practitioners exhibited a nuanced understanding of the ethical issues and values in their work. The political environment of local governmental public health practice engenders ethical challenges that practitioners negotiate with minimal formal assistance.