· Write a response as directed to each of the three case studies and save the document.
1- Analyze the ethical implications of a community health initiative to decrease the rate of teenage pregnancy by means of health education in the public schools. This community takes pride in its schools and is comprised of multiple ethnic, immigrant, religious and social groups. Use the following ethical principles in your analysis: autonomy, beneficence, nonmaleficence and justice.
• The view that everyone is entitled to equal rights and equal treatment. Ideally, each person has an equal share of the goods of society, and it is the role of government to ensure that this happens. The government has the authority to redistribute wealth if necessary to ensure equal treatment. Thus egalitarians support welfare rights—that is, the right to receive certain social goods necessary to satisfy basic needs. These include adequate food, housing, education, and police and fire protection. Both practical and theoretical weaknesses are inherent in egalitarianism.
• The libertarian view of justice advocates for social and economic liberty. While egalitarianism lacks incentives for individuals, libertarianism emphasizes the contribution and merit of individuals (Beauchamp & Childress, 2013).
• Limited role of government
Attempts to develop a theory that values both liberty and equality
• Based on Rawl’s Theory of Justice and the “veil of ignorance.” Behind this veil, people (or their representatives) are unaware of social position, race, culture, doctrine, sex, endowments, or any other distinguishing circumstances (Rawls, 2001). This is known as the original position and is an exercise to address the inequalities and bargaining advantages that result from birth, natural endowments, and historical circumstances. Without these inequalities, all people are free and equal and can work together as citizens to decide what is fair and therefore just. Once impartiality is guaranteed, Rawls suggests all rational people will choose a system of justice containing the following two principles:
• Each person has the same claim to a fully adequate scheme of equal basic liberties, and this scheme is compatible with the same scheme of liberties for all.
• Social and economic inequalities are to satisfy two conditions: first, they are to be attached to offices and positions open all under conditions of fair equality of opportunity; and second, they are to be to the greatest benefit to the least advantaged members of society (the difference principle).
Respect for autonomy: Based on human dignity and respect for individuals, autonomy requires that individuals be permitted to choose those actions and goals that fulfill their life plans unless those choices result in harm to another.
Nonmaleficence: Nonmaleficence requires that we do no harm. It is impossible to avoid harm entirely, but this principle requires that health care professionals act according to the standards of due care, always seeking to produce the least amount of harm possible.
Beneficence: This principle is complementary to nonmaleficence and requires that we do good. We are limited by time, place, and talents in the amount of good we can do. We have general obligations to perform those actions that maintain or enhance the dignity of other persons whenever those actions do not place an undue burden on health care providers.
Distributive justice: Distributive justice requires that there be a fair distribution of the benefits and burdens in society based on the needs and contributions of its members. This principle requires that, consistent with the dignity and worth of its members and within the limits imposed by its resources, a society must determine a minimal level of goods and services to be available to its members.a”
2- You are a public health nurse committed to supporting health and equity in all policies. Imagine that you are working in a community with a large number of homeless people. The climate is mild, and the people live openly in the street and parks. A proposal is to come before the city council to strengthen the vagrancy ordinance in order to promote tourism. As a community health nurse working with the homeless, you have been asked to provide testimony. What will your position be and how will you defend it ethically? Use specific principles in the Principles of the Ethical Practice of Public Health (Box 7.4 in Chapter 7 of Stanhope and Lancaster, 2020) as you support your testimony.
Principles of the Ethical Practice of Public Healtha
1. Public health should address principally the fundamental causes of disease and
requirements for health, aiming to prevent adverse health outcomes.
2. Public health should achieve community health in a way that respects the rights of individuals in the community.
3. Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members.
4. Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all.
5. Public health should seek the information needed to implement effective policies and programs that protect and promote health.
6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation.
7. Public health institutions should act in a timely manner on the information they have, within the resources and the mandate given to them by the public.
8. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community.
9. Public health programs and policies should be implemented in a manner that most enhances the physical and social environment.
10. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others.
11. Public health institutions should ensure the professional competencies of their employees.
12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.
aA section of the Public Health Code of Ethics is presented.
Reprinted with permission from the Public Health Leadership Society: Public health code of ethics, 2002, American Public Health Association (APHA). Available at http://phls.org.
Commonalities exist between the Code of Ethics for Nurses With Interpretative Statements and the Public Health Code of Ethics. Both codes provide general ethical principles and approaches that are enduring and dynamic. They require nurses and public health personnel to think and act in accordance with the underlying ethics of their profession. Of note, they each encourage evidence-based and collaborative approaches for the betterment of health. Although the two codes do not specify (nor should they specify) details for every ethical issue, other mechanisms such as standards of practice, ethical decision-making frameworks, and ethics committees provide further guidance. Nevertheless, these two codes address most approaches to ethical justification, including traditional and emerging ethical theories and principles, humanist and feminist ethics, virtue ethics, professional-individual and/or community relationships, and advocacy. Many websites provide further information on codes of ethics and other ethical concerns in public health; all can be accessed through the WebLinks section of this book’s Evolve website. Some of them are noted in the Additional Resources feature at the beginning of the chapter.”
3- The article by Green is an excellent example and discussion of the pros and cons of “Sin Taxes”. As a public health nurse discuss your views on the use of “sin taxes” in general to change health behaviors. Use specific values in the “Contrast of Social Justice and Market Justice as an Advocacy Framework Table” (Table 7.3 in Chapter 7 of Stanhope and Lancaster, 2020) in your discussion.
Case Study: Autonomy and Distributive Justice
Amelia Lewis, a 31-year-old African American woman with multiple mental health diagnoses, has been monitored in the local mental health system for over 10 years. She is the mother of Tyesha, who is three years old. Multiple agencies have monitored Ms. Lewis and her little girl, who live in a sparsely furnished apartment in subsidized housing. A guardian handles all of Ms. Lewis’s financial affairs. Ms. Lewis’s relationship with the father of Tyesha has deteriorated, and he does not live with her.
Ms. Lewis has issues of trust, and she is often suspicious of the care providers who come to her home. She does rely on some of the professionals with whom she interacts on a weekly or biweekly basis. She is both cognitively delayed and suffers from schizophrenia. Her developmental level places her at a stage at which her own needs are her primary focus, and this is not expected to change; her interaction with Tyesha is perfunctory, involving little outward affection. She is unable to understand that Tyesha is not capable of self-care and that her three-year-old child will not always obey when Ms. Lewis instructs her to do something. Tyesha’s needs, level of functioning, and cognitive development are quickly surpassing her mother’s ability to cope. Frustration and misunderstanding ensue when Ms. Lewis thinks that Tyesha does not listen to her, and encouragement and parent education have done little to improve the situation as Tyesha gets older and more assertive. This has made toilet training, provision of an appropriate diet, and other aspects of child care problematic.
Many services besides those for mental health are involved to help this family of two cope. There is concern about abuse or neglect of Tyesha due to Ms. Lewis’s lack of understanding of how to be a parent. Supplemental Security Income provides monetary support because of her mental disability, and they have Medicaid coverage for their health care needs, as well as food stamps and modest financial assistance through Temporary Assistance for Needy Families (TANF). Ms. Lewis cannot currently work and take care of her child due to her mental disability. Before Tyesha’s birth, Ms. Lewis held a job and maintained self-care, but the care of Tyesha has precluded her managing employment at this time. Child Protective Services is also monitoring Ms. Lewis’s situation to determine to what extent she can meet the needs of her child. Ms. Lewis attends a local program to complete her General Education Development (GED), which provides child care during the day. Though Ms. Lewis is not expected to complete her GED, this program provides structured time for Tyesha three times a week. The child is considered developmentally normal at this time, and an infant development program monitors her progress on developmental issues. The Child Health Partnership, an agency that addresses the needs of challenged families, provides regular visits, family support, and parenting education, and the GED teachers make regular home visits to check on Ms. Lewis and Tyesha. Ms. Lewis thinks things are going just fine.
The Child Health Partnership nurse is concerned about this family and thinks that some permanent resolution of the situation is inevitable. There is minimal coordination of services, and there is no “lead agency” in the family’s care. Choose one of the ethical decision processes or one set of code of ethics discussed in the chapter, and discuss and debate these questions:
1. Should the nurse involved in the Child Health Partnership program initiate any action to try to coordinate the work of the many agencies involved with this family?
2. Who has a professional responsibility to determine when the mother can no longer cope with the developing child?
3. Whose needs, Ms. Lewis’s or Tyesha’s, should take precedence?
4. Using one of the ethics decision processes, analyze the role of the nurse in this situation. For example, considering the utilitarian ethics decision process, decide if it is morally right for you to take the child away from the mother. If you do this, what are the implications for the mother, the child, and the community? What would be the possible consequences of removing the child? Of not removing the child? What principles can best guide your decision making? What possible moral dilemmas will you experience?
5. Safety is a core concept of public health nursing. Using two of the six quality and safety competences (patient-centered care and safety) for nurses identified in the Quality and Safety Education for Nurses (QSEN) work, develop a plan of action for the nurse who is caring for this family.
Use the Code of Ethics for Nurses to guide your nursing practice.
If you are unable to behave in accordance with the Code of Ethics for Nurses (e.g., you speak in a way that does not communicate respect for a client), take steps to correct your behavior.
If you have treated a client or staff member in a way that is inconsistent with ethics practices, seek guidance on other choices you could have made.”