Principles, ethics and budgeting during a time of scarcity

Despite much theoretical work in how and what type of ethical principles ought to be utilized in public health practice, there is little empirical understanding of how and where ethical principles and concepts actually are utilized, explicitly or implicitly, in practice. This presentation seeks to address this gap in knowledge -- specifically in how ethics is used in budget and priority setting at state health agencies. This mixed-methods project took place in two stages. First, 45 semi-structured interviews were conducted with state public health leaders across six state health agencies. Stage 2 consisted of a survey of all 50 states and DC; we received 207 responses (67% response-rate). In both stages, executives and division/bureau heads served as respondents. Respondents reported three main types of guiding principles and values used in resource allocation decision-making: 1) Specific criteria or goals (e.g. promote prevention, maximize return on investment, protect the vulnerable); 2) Compliance-oriented (e.g., meet mandates, align with political directives, follow federal guidance); and 3) Virtues they wish to exemplify or inspire in others (e.g., honesty, transparency, inspiring leadership). Very few said they actually felt they were explicitly utilizing ethical principles; this may be in part due to a common identification of ‘Ethics' as Professionalism/Compliance Oriented (e.g., professional codes of ethics). This project identifies several opportunities for public health ethics to more directly engage with public health practitioners - namely around perception of what ethical principles are and mean for resource allocation, using a common language, and tool creation for practitioners.