Ethical Dilemma Preparation This assignment uses a case study approach. Familiarize yourself with the case studies in the ethic

Instructions

Select one of the case studies. Determine which of the Belmont principles of ethics have been violated and explain why you identified those principles. Develop a 3–5 page resolution proposal to address the dilemma.

To complete this assignment successfully, you must include the following:

· Clarify an ethical dilemma faced by a public health practitioner.

· Discuss the consequences of an action related to an ethical dilemma in public health.

· Discuss the health and wellness values of the stakeholders as they pertain to the ethical

dilemma faced by the organization or individual.

· Compare and contrast alternative courses of action.

· Communicate respect for the diversity, dignity, and integrity of people involved in the attempt

to resolve an ethical dilemma in public health.

Format your assignment using this structure:

· Title page.

· Brief summary of the case study.

· A description of how and why the identified Belmont principles are being violated.

· Overview of resolution.

· Reference page.

Additional Requirements

· Page count: Your assignment should consist of 2–4 double-spaced pages of content plus cover

and reference pages.

· Font: Times New Roman, 12 points.

· APA Formatting: Resources and citations are formatted according to current APA style and

format.

· Number of references: Cite at least two peer-reviewed resource.

An American Family: Ethical Dilemma

· Introduction

· Case Studies

· Conclusion

· Credits

Ethical Dilemma

Public health seeks to improve population health by working through social rather than individual interventions. Because the focus is on populations, some public health functions — such as disease reporting requirements, which may violate patient confidentiality — are considered allowable exceptions to accepted ethical rules. But it is important to understand that these exceptions do not negate the need to consider the ethical implications of public health policies and practices. Indeed, because public health actions can have such far–reaching outcomes, ethical considerations become very important.

Case Studies

In this activity, you will select one of the case studies and analyze it in terms of ethical violations, using the Belmont principles as your guidelines. You will also analyze the consequences of choices made and who the stakeholders are.

The Belmont Report summarizes the basic ethical principles identified by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research.

The following are excerpts from the Belmont Report (Department of Health, Education, and Welfare, 1979).

The Belmont Report

Part B: Basic Ethical Principles

The expression “basic ethical principles” refers to those general judgments that serve as a basic justification for the many particular ethical prescriptions and evaluations of human actions. Three basic principles, among those generally accepted in our cultural tradition, are particularly relevant to the ethics of research involving human subjects: the principles of respect of persons, beneficence and justice.

· Respect for Persons. Respect for persons incorporates at least two ethical convictions: first, that individuals should be treated as autonomous agents, and second, that persons with diminished autonomy are entitled to protection. The principle of respect for persons thus divides into two separate moral requirements: the requirement to acknowledge autonomy and the requirement to protect those with diminished autonomy.

An autonomous person is an individual capable of deliberation about personal goals and of acting under the direction of such deliberation. To respect autonomy is to give weight to autonomous persons' considered opinions and choices while refraining from obstructing their actions unless they are clearly detrimental to others. To show lack of respect for an autonomous agent is to repudiate that person's considered judgments, to deny an individual the freedom to act on those considered judgments, or to withhold information necessary to make a considered judgment, when there are no compelling reasons to do so.

However, not every human being is capable of self–determination. The capacity for self–determination matures during an individual's life, and some individuals lose this capacity wholly or in part because of illness, mental disability, or circumstances that severely restrict liberty. Respect for the immature and the incapacitated may require protecting them as they mature or while they are incapacitated.

Some persons are in need of extensive protection, even to the point of excluding them from activities which may harm them; other persons require little protection beyond making sure they undertake activities freely and with awareness of possible adverse consequence. The extent of protection afforded should depend upon the risk of harm and the likelihood of benefit. The judgment that any individual lacks autonomy should be periodically reevaluated and will vary in different situations.

In most cases of research involving human subjects, respect for persons demands that subjects enter into the research voluntarily and with adequate information. In some situations, however, application of the principle is not obvious. The involvement of prisoners as subjects of research provides an instructive example. On the one hand, it would seem that the principle of respect for persons requires that prisoners not be deprived of the opportunity to volunteer for research. On the other hand, under prison conditions they may be subtly coerced or unduly influenced to engage in research activities for which they would not otherwise volunteer. Respect for persons would then dictate that prisoners be protected. Whether to allow prisoners to “volunteer” or to “protect” them presents a dilemma. Respecting persons, in most hard cases, is often a matter of balancing competing claims urged by the principle of respect itself.

2. Beneficence. — Persons are treated in an ethical manner not only by respecting their decisions and protecting them from harm, but also by making efforts to secure their well–being. Such treatment falls under the principle of beneficence. The term “beneficence” is often understood to cover acts of kindness or charity that go beyond strict obligation. In this document, beneficence is understood in a stronger sense, as an obligation. Two general rules have been formulated as complementary expressions of beneficent actions in this sense: (1) do not harm and (2) maximize possible benefits and minimize possible harms.

The Hippocratic maxim “do no harm” has long been a fundamental principle of medical ethics. Claude Bernard extended it to the realm of research, saying that one should not injure one person regardless of the benefits that might come to others. However, even avoiding harm requires learning what is harmful; and, in the process of obtaining this information, persons may be exposed to risk of harm. Further, the Hippocratic Oath requires physicians to benefit their patients “according to their best judgment.” Learning what will in fact benefit may require exposing persons to risk. The problem posed by these imperatives is to decide when it is justifiable to seek certain benefits despite the risks involved, and when the benefits should be foregone because of the risks.

The obligations of beneficence affect both individual investigators and society at large, because they extend both to particular research projects and to the entire enterprise of research. In the case of particular projects, investigators and members of their institutions are obliged to give forethought to the maximization of benefits and the reduction of risk that might occur from the research investigation. In the case of scientific research in general, members of the larger society are obliged to recognize the longer term benefits and risks that may result from the improvement of knowledge and from the development of novel medical, psychotherapeutic, and social procedures.

The principle of beneficence often occupies a well–defined justifying role in many areas of research involving human subjects. An example is found in research involving children. Effective ways of treating childhood diseases and fostering healthy development are benefits that serve to justify research involving children — even when individual research subjects are not direct beneficiaries. Research also makes it possible to avoid the harm that may result from the application of previously accepted routine practices that on closer investigation turn out to be dangerous. But the role of the principle of beneficence is not always so unambiguous. A difficult ethical problem remains, for example, about research that presents more than minimal risk without immediate prospect of direct benefit to the children involved. Some have argued that such research is inadmissible, while others have pointed out that this limit would rule out much research promising great benefit to children in the future. Here again, as with all hard cases, the different claims covered by the principle of beneficence may come into conflict and force difficult choices.

3. Justice. — Who ought to receive the benefits of research and bear its burdens? This is a question of justice, in the sense of “fairness in distribution” or “what is deserved.” An injustice occurs when some benefit to which a person is entitled is denied without good reason or when some burden is imposed unduly. Another way of conceiving the principle of justice is that equals ought to be treated equally. However, this statement requires explication. Who is equal and who is unequal? What considerations justify departure from equal distribution? Almost all commentators allow that distinctions based on experience, age, deprivation, competence, merit and position do sometimes constitute criteria justifying differential treatment for certain purposes. It is necessary, then, to explain in what respects people should be treated equally. There are several widely accepted formulations of just ways to distribute burdens and benefits. Each formulation mentions some relevant property on the basis of which burdens and benefits should be distributed. These formulations are (1) to each person an equal share, (2) to each person according to individual need, (3) to each person according to individual effort, (4) to each person according to societal contribution, and (5) to each person according to merit.

Questions of justice have long been associated with social practices such as punishment, taxation and political representation. Until recently these questions have not generally been associated with scientific research. However, they are foreshadowed even in the earliest reflections on the ethics of research involving human subjects. For example, during the 19th and early 20th centuries the burdens of serving as research subjects fell largely upon poor ward patients, while the benefits of improved medical care flowed primarily to private patients. Subsequently, the exploitation of unwilling prisoners as research subjects in Nazi concentration camps was condemned as a particularly flagrant injustice. In this country, in the 1940's, the Tuskegee syphilis study used disadvantaged, rural black men to study the untreated course of a disease that is by no means confined to that population. These subjects were deprived of demonstrably effective treatment in order not to interrupt the project, long after such treatment became generally available.

Against this historical background, it can be seen how conceptions of justice are relevant to research involving human subjects. For example, the selection of research subjects needs to be scrutinized in order to determine whether some classes (e.g., welfare patients, particular racial and ethnic minorities, or persons confined to institutions) are being systematically selected simply because of their easy availability, their compromised position, or their manipulability, rather than for reasons directly related to the problem being studied. Finally, whenever research supported by public funds leads to the development of therapeutic devices and procedures, justice demands both that these not provide advantages only to those who can afford them and that such research should not unduly involve persons from groups unlikely to be among the beneficiaries of subsequent applications of the research.

Reference

Department of Health, Education, and Welfare (1979). The Belmont report: Ethical principles and guidelines for the protection of human subjects of research. Retrieved from https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/index.html

Enforcement of Lead Paint Standards

The following case study comes from Good Decision Making in Real Time: Public Health Ethics Training for Local Health Departments (DHHS, CDC, 2017).

Protection of Underserved or Marginalized Populations

What special obligations does public health have to underserved and marginalized populations? Protecting the public's health is a core public health value. Because underserved and marginalized populations exhibit greater susceptibility to those factors that cause morbidity and mortality, protecting these populations requires greater care and vigilance. Well–intentioned efforts to help these populations often have unforeseen consequences that can result in greater harm to them.

Analyze the situation:

Your community is a mid–sized city located in the northeastern United States. Like many other jurisdictions, the city is facing difficult financial times. More than 30 percent of homeowners owe more than their houses are worth and demands for social services are near all–time highs. The waiting time for public housing exceeds two years, and the proportion of families in the city without health insurance is above 15 percent.

One afternoon you receive a call from Dr. Jackie Smith, the head of your environmental health division. In your state, statute delegates many environmental health and safety issues to local health departments, including residential lead inspection and lead hazard remediation.

Dr. Smith says that a growing number of homeowners with a lead poisoned child have told her that they cannot afford to fix up their home and cannot qualify for state or federal support because the cost of lead hazard remediation outstrips the value of their home or it is in too poor a condition otherwise to qualify for grants. In addition, grants to homeowners have requirements that the owners often cannot meet, including being current on property tax and having homeowner's insurance. The state law that requires lead hazard remediation in these homes also created a fund to assist homeowners like these who “fall through the cracks,” but no state funds have been appropriated.

Dr. Smith fears that many of these families will be forced into homelessness or have their children put into protective services if their homes are placarded and condemned. Dr. Smith has asked you, the local health director, to provide input on under what circumstances homeowners should be given extensions beyond the 30—60 day timeframe to complete lead hazard remediation measures.

Reference

Department of Health and Human Services & Centers for Disease Control (2017). Good decision making in real time: Public health ethics training for local health departments. Retrieved from https://www.cdc.gov/od/science/integrity/phethics/docs/Student_Manual_Revision_June_6_2017_508_compliant_Final.pdf

Smoke–Free Policies in Outdoor Public Spaces

The following case study comes from Good Decision Making in Real Time: Public Health Ethics Training for Local Health Departments (DHHS, CDC, 2017).

Balancing the Rights of Individuals with the Protection of the Public Good:

The 1905 Supreme Court case of Jacobson v. Massachusetts over compulsory vaccination law upheld the view that individual freedom is subject to the police power of the state and can be subordinated to the public welfare in situations where public safety demands it. This ruling provides a general mandate for public health to restrict individual liberty, but also establishes a condition for it, namely, protecting the public good. Many ethical issues arise in public health around the tension between individual and community interests. Resolving them often involves weighing liberty restrictions against potential harms or threats to public health and safety.

Analyze the situation:

An outdoor smoke–free policy has recently been proposed by your community's Board of Health. The policy would apply to all public parks and beaches. The Board has called you, the local health department director, to testify at the upcoming hearing on the potential policy. How would you, as the local health department director, evaluate whether and how the policy should be enacted?

Reference

Department of Health and Human Services & Centers for Disease Control (2017). Good decision making in real time: Public health ethics training for local health departments. Retrieved from https://www.cdc.gov/od/science/integrity/phethics/docs/Student_Manual_Revision_June_6_2017_508_compliant_Final.pdf

In 2015, Blanca Borrego went to a women's healthcare clinic seeking treatment for an abdominal cyst. She completed the paperwork she was given by the clinic staff and was told to wait in the reception area. After several hours, she was called to the exam room, where she was met by immigration officers. She was taken away in handcuffs and the officers told her daughters that she would be deported(Maruca, 2015).

Reference

aruca, W. (2015, September 25). Did practice violate HIPAA by tipping off immigration authorities? [Blog post] Retrieved from https://hipaahealthlaw.foxrothschild.com/2015/09/articles/articles/did-practice-violate-hipaa-by-tipping-off-immigration-authorities

An American Family

Protected Information and the Government

Analyze the situation:

Alicia Ramirez is a third–generation Latina American, living in Minneapolis, Minnesota. Alicia was born in Monterrey, Mexico, where Alicia's parents met, but she has lived in the US since she was two years old. Alicia's uncle Eduardo recently died from smoking–related illnesses and his daughter, Almira, confided to Alicia that while she also smoked cigarettes, she was ready to quit. Alicia helped Almira find a clinic that would help her quit successfully and Almira made an appointment to begin the cessation program.

On the day of the appointment, Alicia texted her cousin to see how it had gone. Almira informed Alicia that she had left the clinic when they gave her several forms to complete.

“I didn't know I'd have to fill anything out. I can't do that… you know we don't have legal papers, Almira said. Alicia.” After a few phone calls, Alicia determined that the forms were intended to gather basic patient information. Additionally, they also had given Almira a standard HIPAA disclosure form.

“The HIPAA form is intended to explain a patient's rights. I'm surprised she found it threatening” the clinic manager said when Alicia spoke with her. After a few questions, Alicia realized that all the forms were in English. While Almira's spoken English is good, she has a limited vocabulary in English and does not read it well at all.

Alicia offered to go with her cousin to a rescheduled first appointment, but she found herself wondering how the situation could be improved for other people in similar situations. She wondered how many undocumented immigrants might be avoiding health care altogether because of worries about the paperwork they were being asked to complete.

Conclusion

The Belmont principles provide a framework to analyze health policy and actions. Using this framework, you have begun your analysis of the case you selected.

When you return to the course room, you will use your responses to these questions about the case you selected to complete your assignment. You can return to this activity at any time to review the information or to view the other cases, if you wish

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