Awareness, attitude and experiences regarding public health ethics of public health professionals

Abstract

AimHealthcare ethics is closely related and similar to medical ethics; however, it is not limited to this. The basic distinction between healthcare ethics and traditional medical ethics is that public health specialists deal with the health problems of societies rather than health problems of individuals. Public health ethics is a current and important field that needs to be studied. The aim of this study is to question the experiences of public health practitioners in public health ethics and professional ethics for the purpose of strengthening the ethical dimension of staff, identifying their awareness, and determining their attitudes and understanding on this topic.MethodsThe study was conducted between 03.02.2016 and 15.03.2016 with public health professionals that were registered in the Communication Group of Halk Sağlığı Uzmanları Derneği (HASUDER).ResultsTwo hundred ninety-nine people participated in our study. According to the results of our study, all of the H0 Hypotheses that were formed by us were rejected. There is a significant difference between the experience, awareness, and attitudes of the public health professionals who participated in the study in terms of healthcare ethics. Only half of the staff had received public health training in their professional training.ConclusionAs indicated in the basic principles of public health ethics, public health should address the health of society in a manner that respects the rights of individuals. Since there are no studies in the literature on healthcare ethics conducted with public health professionals in our country, our study is one of the pioneering ones in this field. The training of public health professionals in healthcare ethics is not adequate, and they feel the need to receive training in this field.

Keywords

Introduction

According to Last, public health is “the combination of sciences, skills, and beliefs that is directed to the maintenance and improvement of the health of all the people through collective or social actions”.¹ With global transformation seen over the past 30 years, these conventional functions of public health have been complemented by the reduction of rapidly increasing health inequalities.² The modern approach to public health considers social well-being to be a necessary condition for good human health (“Health Promotion Training” Guide for Community Health Center Staff. T.R. Ministry of Health, General Directorate of Basic Health Services, Department of Health Promotion and Development. Ankara: 2011;7. In Turkish). One of the most important social objectives of public health is the improvement of living conditions of individuals.³ Given this social aspect, public health is a multi-disciplinary science and plays an integrative role among all disciplines (HASUDER Health policies and employment working group REPORT, 2014).EthicsEthics, most plainly defined as “moral philosophy” or “contemplation of moral principles”, is one of the four disciplines of philosophy (ontology, epistemology, ethics, and aesthetics). Ethics became an applied science in the second half of the twentieth century.⁵ The existence of various religious, national, ethnic, and sexual identities in a society raises different moral understandings. In ethics, the concept of “desired good” is more recognized and universal.⁶ “Ethics is not a matter of dwelling within the framework of virtuous emotions nor is it of pointing the finger at others. Ethics should be addressed as a critical science of thought.”⁷Public Health EthicsPublic health ethics is closely related to medical ethics, especially bioethics. Medical ethics may be insufficient in fulfilling the needs of health care professionals. While medical ethics is patient-oriented and takes on an individual viewpoint, public health ethics also requires a social perspective.⁸ The main difference is that public health professionals are more involved in the health of society rather than the health of individuals.⁹ The main categories of public health principles are as follows:¹⁰
• Ensuring well-being
• Be autonomous and respect the autonomy of others
• Do no harm
• Justice and equity
Public health outlines general approaches, but it may often ignore individual differences and priorities.¹¹Occupational EthicsOccupational ethics is the sum of ethical standards and principles that guide the conduction of professional activities.¹² Occupational ethics are believed to be universal.¹³ The basic common ground of ethics and law is that they are rule-making systems.¹⁴BioethicsBioethics is an interdisciplinary academic field of study in which, besides medical actions, issues of value in human interactions with the environment and nature are also scrutinized.¹⁴ The philosophy of public health, which prioritizes benefit to society, is sometimes confronted with the basic philosophy of ethics that prioritizes individual benefit.¹⁵ Beauchamp and Childress indicated that in the solution to ethical problems encountered in medical practice, any one or more of the ethical principles may be selected according to the circumstances, and that some principles may be sacrificed. However, there must be a valid and grounded reason to violate an ethical principle; infringement should be done with minimum harm for the purpose of the planned action, and the person who infringes the principle must try to minimize the effects of the violation.¹⁶Drifting on IceMaking a mistake in the choice of principle infringement is plainly defined as the concept of “ethical drift”.¹⁷
This study aims to question the experiences of practitioners, especially conflicts between public health ethics and occupational ethics, in order to strengthen the ethical dimension of public health practices, to reveal awareness, and determine their understanding and attitudes. By presenting inadequacies, if any, from training up until the field of practice and providing solutions, it is also aimed to contribute to improving the effectiveness of public health services for the future society and respectability towards the profession. Finally, the perceptions and attitudes of public health professionals towards public health ethics in Turkey will also be determined.

Materials and Methods

The study was conducted between 02/03/2016–03/15/2016 with public health professionals registered to the HASUDER contact groups. The 517 people registered to the contact group with available email addresses were accepted to the study population. A total of 44 people were excluded from the study, of whom 18 were retired and not actively employed, 12 continued working in a different branch, and 14 were educators at a department of medical education and were not actively participating in public health practices.
The questionnaire we developed was sent through a web-based survey preparation and collection program to a total of 473 people who had personal e-mail addresses and were eligible to participate in our research, consisting of 133 professors, 77 associate professors, 46 assistant professors, 11 lecturers, and 206 specialists/PhDs. Since some university email systems block survey programs, and the questionnaire that we sent was automatically sent to junk email folders, those people were called by phone and informed that the questionnaire had been sent.
People who did not respond to the questionnaire were sent a new invitation to participate after five days. Participants who had begun to answer the survey questions but had not completed the survey were sent a reminder message after seven days requesting completion of the survey.
The five-part questionnaire consisted of 14 demographic questions in part one, eight questions on experience in part two, five questions on awareness in part three, 16 questions on thoughts in part four, and 22 questions on attitude in part five, 65 questions in total. A total of 43 questions about awareness, thoughts, and attitude in the last three parts were five-point Likert scales.
The study was planned as a cross-sectional, analytical study. When all public health professionals registered to the HASUDER contact groups were accepted as the study population, with p-value 0.5 and q-value 0.5, in order to maintain the study power of 80%, a response from at least 203 participants was expected. Alpha margin of error was considered 5%.
The Chi-square test was used in the statistical analyses of the tables. The Stepwise Logistic Regression method was used in the comparisons of attitudes towards ethical cases according to gender and other variables.Ethical ApprovalEthics Committee approval for the study was obtained.

Results

The distribution of titles of the study participants was as follows: 92 professors (30.7%), 57 associate professors (19.1%), 30 assistant professors (10.1%), 9 lecturers (3.0%), and 111 specialists/doctorates (37.1%). A total of 299 people participated in our study, of which 166 (55.5%) were females and 133 (44.5%) were males.
While 213 (74.5%) of the participants indicated that they had previously participated in an ethical study at least once in their career, 156 (55.1%) believed that it could solve ethical conflicts encountered during public health practices.
One hundred fifty-eight of the participants (57.0%) thought that public health professionals did not have the minimum level of education, knowledge, and competence required by their profession, and 169 (61.0%) thought that the education of public health professionals in Public Health Ethics was insufficient.
Fifty-six (18.7%) of the participants stated that they did not receive any ethics courses during their undergraduate and professional education, and 143 (50.4%) stated they felt the need to attend an educational course on public health ethics. When the two groups were compared, it was observed that the participants who had taken ethics courses were more able to recognize ethical conflicts (p<0.05) (Table 1).
While 272 (98.2%) of the participants indicated that they, as public health professionals, acted according to ethical principles, 183 (66.0%) believed that among public health professionals there were colleagues who did not comply with public health ethics.
Results of Stepwise logistic regression analysis showed that 3.3 times more males compared to females indicated that they may have made decisions that did not comply with ethical principles throughout their occupational experiences (95% CI: 1.2–8.8) (Table 1).
When participants were asked about possible reasons why public health professionals behave in contradiction to public health ethics, 146 (51.1%) participants replied with “Incompetence” and 127 (44.4%) responded with “Inadequate training”, ranking second. Of the participants, 253 (88.5%) indicated that they have witnessed their colleagues taking responsibility in a matter in which they were authorized but insufficient.
Thirty-nine (49.4%) of the 79 professionals working at the Ministry of Health and 148 (73.6%) of the 201 professionals working outside of the Ministry of Health stated that they had refused to take responsibility in a matter in which they felt inadequate. When these two groups were compared, it was observed that the majority of professionals working outside of the Ministry of Health declined to take responsibility when they felt inadequate (p<0.05).
Thirty-three (41.8%) of 79 participants who were Ministry of Health personnel and 59 (28.9%) of 204 participants who were not Ministry of Health personnel for a total of 92 (32.5%) participants indicated that they had been under pressure to act outside ethical principles. This majority was higher in Ministry of Health personnel (p<0.05) (Table 1).
Two hundred and nine (75.5%) study participants were of the belief that not all legal actions were ethical.
While 168 (60.6%) of the participants stated that differences between the political views of public health professionals made it difficult to comply with occupational ethics rules, 220 people (79.4%) stated that the balance of social power affected the ethical attitudes of public health professionals.
While 201 participants (72.7%) stated that public health professionals should prioritize public interests above the individual interests within the framework of public health ethics in their daily practices, 134 participants (50.9%) believed that informed consent could be given up for community immunity (Table 2).

Discussion

Due to the lack of studies on public health ethics in the literature, our study is one of the pioneering studies on this subject. According to our results, all of our H0 hypotheses were rejected. It was observed that there were differences between the public health professionals who participated in our study in terms of experiences, awareness, and attitudes towards public health ethics in daily practices.
The reason “Incompetence” was the top reason public health professionals were thought to behave in contradiction to public health ethics may be due to the fact that 253 (88.5%) of the participants witnessed that their colleagues were responsible but not sufficient during their professional experience. Ministry of Health personnel indicated that they were under more pressure to act outside ethical principles (p<0.05). This may be because Ministry of Health personnel are more exposed to Ministry of Health sanctions.
Similar to our study, Kutluk et al. (Kutluk AF. Evaluation of Ethics in Behavioral Accounting Framework (thesis). Antalya: Akdeniz University Institute of Social Sciences, Department of Business Administration; 2010. In Turkish) observed that there was a significant difference between the scores of ethical judgment levels of professional accountants according to gender. It was found that women had higher ethical judgement levels compared to men.
On the other hand, differences between men and women according to ethical approaches may be due to the decisions of men and women in working life or attitudes towards accepting/avoiding roles. It would be appropriate to further investigate this situation with new studies.
One hundred sixty-eight (60.6%) public health professionals who participated in our study indicated that they believed political views complicated the compliance with occupational ethics principles. Similar to our study, Yıldız et al.¹⁸ found that differences in political views were harmful to occupational ethics.
Two hundred nine (75.5%) of the study participants stated they believed that not all legal actions were ethical. As reported in a study by Kutlu et al.¹⁹ occupational ethics is based on higher judgements considered compulsory, and even above the law. It is impossible to completely transfer ethical values to laws. Therefore, ethics always hold a place above laws.
Only about half of the study participants believed that informed consent could be waived for community immunity. As indicated in the basic principles of public health ethics, public health should address the health of society in a manner that respects the rights of individuals.¹² This result, found in our study, may be because participants experience dilemmas between individual rights and community immunity, especially as a result of anti-vaccination policies in recent years.

Limitations

• Since all data were based on the participants’ statements, these statements were considered correct.
• As not everyone who works as a public health specialist is a member of HASUDER, access to their contact information was a problem. People whose contact information was accessible from medical congresses were invited to participate in the study.
• The websites of the institutions they worked for were used to find the titles of the persons who were contacted from the mailing list obtained from HASUDER. Information on these websites was assumed to be up to date.
• Since the information obtained from HASUDER did not include information on the institutions that the public health professionals worked at, the representation of the study population according to the institutions employing the participants could not be tested.
• Of the 473 public health professionals who met the criteria, 63.2% participated in the study. Had the remaining 36.8% of public health professionals participated, there would have been a possibility of change in study results.
• Since there is a limited number of studies on public health ethics in the literature, no similar studies have been found to be used as an example.

Conclusion

According to our study, over half of public health professionals are insufficiently educated in public health ethics. Almost all of the participants saw their colleagues assume responsibility for matters that they were authorized but insufficient. Ministry of Health personnel had a higher prevalence of non-ethical behavior compared to non-Ministry of Health personnel. About half of public health professionals require education in public health ethics.
Only half of public health professionals believed that informed consent could be waived for community immunity. Women behaved more ethically compared to men. Educational programs on occupational ethics should contribute to the development of doctors who can preserve and apply occupational ethics principles.
In order to prevent differences between the political views of colleagues and the balance of power in social life from affecting ethical attitudes, the first condition in distributing assignments and positions should be based on competence. Necessary arrangements should be made to prevent the dilemma between laws and ethical values when public health professionals are performing their duties, and the principles of universal ethical values should be transferred to laws.

Declarations

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