Public policy in relation to the ethical dilemma
For the case study, we will be examining the topic of public policy in relation to the ethical dilemma below.
Public health policy is incredibly nuanced, and is a field that many people receive advanced degrees in before working in this area.
Paternalism and other ethical principles may be present, but the goal is to support existing policies around smoking cessation perhaps or suggest a new best course of action based on your public health KNOWLEDGE
Introduction:
Kass argues that an ethical approach in public health is one that places the fewest burdens on individuals’ health without significantly reducing the potential benefits of intervening.(1)
Yet many population health regulations are highly intrusive, compromising individual liberty and imposing penalties for non-compliance. Moreover, the benefits of these regulations and the burdens they impose may not be shared equally. When developing interventions, the state has, therefore, an obligation to consider the benefits and burdens, particularly on those vulnerable to health inequities and other disparities.(2)
The prevalence of smoking in the general population of Canada is low (18%), but remains elevated in certain sub-populations,(3) raising the possibility that universal tobacco control policies may impose disproportionate burdens on some and exacerbate health inequities.(4) Outdoor smoke-free policies are being increasingly introduced within Canada even as evidence remains inconclusive about the risks of second-hand smoke exposure in outdoor settings and the efficacy of such bans. To remain consistent with Kass’ definition of an ethical approach, the design and implementation of outdoor smoke-free policies should question whether these bans could result in an imbalance of benefits and burdens. Further, whether such bans increase the stigmatization of smokers and, in so doing, violate a core ethical principle and potentially increase health inequities should also be considered.(4,5)
Case:
Municipalities in Canada are increasingly prohibiting smoking in parks, beaches and other outdoor public spaces. Smoke-free spaces are primarily justified on the basis of three goals:
reducing exposure to second-hand smoke;
(ii) encouraging people to quit smoking; and
(iii) preventing youth smoking initiation.(6)
Does evidence demonstrate that such bans effectively, equitably and ethically accomplish these goals? Smoke-free policies in parks and on beaches may have a small positive population health impact. Such policies may reduce second-hand smoke exposure by eliminating the combination of circumstances that creates sufficient concentration of tobacco smoke to pose serious health risk; such bans may also facilitate smoking cessation or reduction for some people.
There is little evidence to date, however, that smoke-free policies in parks and on beaches have an impact on the prevention of smoking initiation among youth. As well, the documented positive benefits may be offset by other, unintended consequences, such as when the stigmatization of smoking makes it harder for some smokers to quit or contributes to stigmatization.(4, 7-9)
While smoking prevalence among the general population in Canada (as in many high-income countries) is relatively low and declining, smoking rates are disproportionately high among youth,(3) low-income adults,(10) people with substance use disorders and/or mental illness(11-15). These uneven rates of smoking both reflect and contribute to social and geographical health inequalities.(4)
Universal outdoor smoke-free policies may have different effects on such sub-groups of smokers, including their use of tobacco, exposure to tobacco smoke and responses to smoking restrictions.(16)
Paradoxically, by limiting the settings in which smoking is allowed, smoking restrictions in public spaces may increase the concentration of second-hand smoke in private indoor spaces such as homes and cars and prompt strategies of resistance rather than compliance.(4) This could be particularly problematic for those without access to safe outdoor spaces and, by increasing exposure to tobacco smoke indoors, may undermine potential health benefits. Moreover, smoking restrictions in public spaces are intended to reduce the prevalence of tobacco use, in part by reducing the social acceptability of smoking.(17-19) Such denormalization of tobacco segregates smokers, makes them an identifiable minority, may compound experiences of social isolation and marginalization and may contribute to poorer quality of health among individuals who already face discrimination on multiple levels.(4, 7, 8, 20, 21)
Stigmatization may contribute to poorer health outcomes and greater health inequity by generating higher levels of stress and contributing to reluctance to seek care.(22) Moreover, some argue that, by definition, the use of stigma as a public health strategy is inherently unethical because it is dehumanizing through its use of shaming to exert social control.(5)
Additional Information:
Smoking is a known harm with no safe exposure levels.(8) It is beneficial to all for a society to take the view that it ought to be reduced to the greatest possible extent. Admittedly, we sufficiently value the idea of individual liberty that we allow people to choose to smoke (putting to one side the issue of nicotine addiction). However, this does not mean that individuals ought to be free to potentially influence others to adopt damaging lifestyles. The important issue here is that we are dealing with public behaviour, not that the smoking occurs outside. Discussion of public health ethics ought to take seriously the nature of public health activity(10) and the kinds of values that are important in public health activity.(11, 12)
References:
Kass, N. E. (2001). An ethics framework for public health. Am J Public Health. 2001;91(11):1776-1782.
2. Childress, J. F., Faden, R. R., Gaare, R. D., et al. (2002). Public health ethics: Mapping the terrain. J Law Med Ethics. 2002;30(2):170-178.
CTUMS. (2010). Canadian Tobacco Use Monitoring Survey (CTUMS) 2010. Retrieved from: http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/ stat/ctums-esutc_2010-eng.php
NOTE: I DONT UNDERSTAND THE QUESTION HERE, IS SOMEONE ABLE TO SPOT AND ANSWER THE ETHICAL DILEMMA IN THIS CASE STUDY
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