摘要：Objectives. We sought to ascertain the types of ethical challenges public health practitioners face in practice and to identify approaches used to resolve such challenges. Methods. We conducted 45 semistructured interviews with public health practitioners across a range of occupations (e.g., health officers, medical directors, sanitarians, nurses) at 13 health departments in Michigan. Results. Through qualitative analysis, we identified 5 broad categories of ethical issues common across occupations and locations: (1) determining appropriate use of public health authority, (2) making decisions related to resource allocation, (3) negotiating political interference in public health practice, (4) ensuring standards of quality of care, and (5) questioning the role or scope of public health. Participants cited a variety of values guiding their decision-making that did not coalesce around core values often associated with public health, such as social justice or utilitarianism. Public health practitioners relied on consultations with colleagues to resolve challenges, infrequently using frameworks for decision-making. Conclusions. Public health practitioners showed a nuanced understanding of ethical issues and navigated ethical challenges with minimal formal assistance. Decision-making guides that are empirically informed and tailored for practitioners might have some value. In 2002, the Public Health Leadership Institute stepped beyond the implicit assumption that an ethical foundation exists for public health practice and formally articulated a code of ethics. 1 The creation of the code was an effort both to clarify and to publicize the ethical underpinnings of the field. Numerous scholars have likewise identified areas within public health practice and policy that they suggest engender ethical issues, tensions, and debate. Often, the literature on public health ethics emphasizes distinctions between ethical challenges that arise in clinical medicine and those that arise in public health practice. Many have argued that the orientation, problems, and values of public health are different enough from those of medicine that the tools and constructs of bioethics or medical ethics are insufficient to address ethical issues in public health. In particular, scholars suggest that the emphasis on individual autonomy in bioethics does not cohere with the population orientation of public health. 2 – 6 Despite the development of the code of ethics and an abundance of theoretical analysis, a dearth of empirical evidence remains about the types and nature of ethical issues faced by public health practitioners and how they approach or resolve such issues. Two previous studies in the United States have examined areas of ethical tension for practitioners. Bernheim 7 conducted 3 focus group interviews with practitioners from different levels of government. These practitioners identified ethical issues in the areas of public–private partnerships, allocation of scarce resources, collection and use of data, and politics. 7 A study of public health nurses in Louisiana reported ethical conflicts in the areas of confidentiality, informed consent, conflict of interest, and whistle-blowing. 8 Although these 2 studies highlighted some ethical issues for practitioners, further development of the empirical knowledge base is essential for progress in the fledgling field of public health ethics. Solid philosophical and empirical grounding may enable theory and practice to validate and enhance each other. A deeper understanding also may help clarify the types of evaluation tools most useful for decision-making and resolution of ethical conflict. To begin to fill these gaps in the literature, we interviewed public health practitioners in Michigan to broaden our understanding of what constitutes an ethical challenge in public health practice and to explore the processes that practitioners use to deal with ethical issues that arise.
