Ethics and public health emergencies: encouraging responsibility

The three primary ethical challenges in preparing for public health emergencies - addressing questions of rationing, restrictions and responsibilities - all entail confronting uncertainty. But the third, considering whether people and institutions will live up to their responsibilities in a crisis, is perhaps the hardest to predict and therefore plan for. The quintessential example of a responsibility during a public health emergency is that of health care professionals' obligation to continue caring for patients during epidemics. Historically, this 'duty to treat' has sometimes gone unrecognized or ignored, but it has also famously been adhered to, including during the recent SARS epidemic. And non-crisis examples of health professionals working in the face of personal risk are very common. The duty to treat should be circumscribed by several considerations, including the levels or risk and benefit at issue, the degree of public reliance on health professional action, and the nature of the individual health professional's acceptance of greater than usual risk. Examining the professional duty to treat and the legitimate questions it raises can provide insight into other actors' responsibilities. Public health ethics as well as professional ethics can help frame answers to some key questions: How strong are ethical responsibilities during crises? To whom do they apply? Should they be more explicit - and hence more circumscribed - or less explicit and hence largely aspirational? And how can public health policies encourage responsible actions?     

Ethics and public health emergencies: rationing vaccines

There are three broad ethical issues related to handling public health emergencies. They are the three R's-rationing, restrictions and responsibilities. Recently, a severe shortage of annual influenza vaccine in the US, combined with the threat of pandemic flu, has provided an opportunity for policy makers to think about rationing in very concrete terms. Some lessons from annual flu vaccination likely will apply to pandemic vaccine distribution, but many preparatory decisions must be based on very rough estimates. What ethical principles should guide rationing decisions, what data should inform these decisions, how to revise decisions as new data emerge, and how to implement rationing decisions on the ground are all important considerations. In addition, ethicists might be able to help policy makers think through the importance of international cooperation in surmounting global rationing dilemmas and to accept the inevitable responsibilities of government in making and implementing rationing decisions.     

Knowledge systems and public health

The knowledge and information systems (KIS) perspective arose from reflections on agricultural development. In the health sector, it is not quite as common to think in terms of KIS. Yet in this complex field, in which health education and promotion play increasingly important roles, the KIS perspective might be very useful. In this article, the authors attempt to apply ideas about KIS and knowledge management to health, by paying attention to the historical development, especially of public health, and by exploring the contribution these ideas could make to the field. Some of the observations made in this attempt are: upstream information flows often are developed poorly, interaction and exchange among the different KIS parties require ongoing stimulation, in special projects and complex communication situations, a system-integrator is needed. Maria Koelen is a staff member of the Department of Extension Science, Wageningen Agricultural University, Hollandseweg 1, 6706 KN Wageningen, The Netherlands, and is responsible for the department's research and courses on health education.     

健康领域的跨期决策与健康行为

健康领域的跨期决策关系着个体和国民的健康和福祉。目前学界对该领域的研究主要停留在参考传统金钱领域的相关理论模型和方法的阶段, 但健康跨期决策具有领域特异性, 沿袭金钱领域理论模型和方法, 导致该领域在研究方法和结果上存在较大的不一致性。健康跨期决策的行为后果是该领域关注重点, 多数研究均报告个体的低时间折扣率、高未来时间取向与其健康保护行为正相关, 与健康风险行为呈负相关。该领域也关注健康跨期决策的影响机制, 如决策对象和决策主体的核心特征等因素。未来研究亟需发展适用于健康领域的跨期决策模型和研究范式, 明确健康行为与跨期决策偏好的关系, 深入探讨健康跨期决策的内在选择机制, 并在健康行为干预和医疗卫生政策应用方面进行更多的尝试和探索。     

Ethics and public health emergencies: restrictions on liberty

Responses to public health emergencies can entail difficult decisions about restricting individual liberties to prevent the spread of disease. The quintessential example is quarantine. While isolating sick patients tends not to provoke much concern, quarantine of healthy people who only might be infected often is controversial. In fact, as the experience with severe acute respiratory syndrome (SARS) shows, the vast majority of those placed under quarantine typically don't become ill. Efforts to enforce involuntary quarantine through military or police powers also can backfire, stoking both panic and disease spread. Yet quarantine is part of a limited arsenal of options when effective treatment or prophylaxis is not available, and some evidence suggests it can be effective, especially when it is voluntary, home-based and accompanied by extensive outreach, communication and education efforts. Even assuming that quarantine is medically effective, however, it still must be ethically justified because it creates harms for many of those affected. Moreover, ethical principles of reciprocity, transparency, non-discrimination and accountability should guide any implementation of quarantine.     

Traumatic stress at work: A public health model

The emergence of the 'New Public Health' movement provides a framework for an integrated and co-ordinated policy for responding to traumatic stress in the workplace. A review of the clinical literature on post-traumatic stress reveals that the components of this framework are available: the challenge is to put in place all the various elements. An organisational response is described which tries to use primary, secondary and tertiary prevention strategies to reduce the impact of traumatic incidents-in this case, armed robberies-on employees of a financial services company. Inter-departmental working, appropriate use of management and social support, pre-trauma training and cognitive-behavioural counselling techniques are all used in an attempt to tailor support to the individual's own needs. Binding the process together is a simple psychological health screening process, offering as a by-product information to improve the responsiveness of the service.