Ask the Ethicist: A new resource for public health students and facultyMay 24, 2019
Submit questions and dilemmas that reflect issues arising in class discussions, practice-based work, or in the way in which we engage with trainees and communities.
The column will be moderated by Carol Runyan and Sara Brandspigel in the Department of Epidemiology as part of their role coordinating the efforts between ColoradoSPH and the Center for Bioethics and Humanities.
For those who have other ethical questions that they do not wish to have considered in this public forum, limited consulting services will be available through the Center for Bioethics and Humanities.
Please submit your questions to firstname.lastname@example.org.
Unless requested specifically, all items are subject to editing and publication in the column, so please do not include personal details.
Here is our first column for "Ask the Ethicist…"
Dear Ask the Ethicist:
Our research study is designed to test the effectiveness of an intervention to prevent suicide among adolescents by training emergency department mental health providers to talk to parents about safe storage of their guns and medications. Hospitals phase into the study at different times to enable comparison of usual care (which may or may not include counseling about safe storage) and the intervention which is training for providers to talk about safe storage, including providing information about where guns may be stored outside the home, a number to find safe disposal sites for medications, and provision of gun safes and medication lockboxes. Parents agree while in the emergency department to be called to learn about the study and, hopefully, participate in follow-up interviews asking about their storage practices and the nature of the encounter at the hospital.
During a recent interview, a parent asked the interviewer for information about where they could store their guns and how to dispose of unused medications. This family had been served by a hospital already participating in the intervention phase where they should have received the packet of materials containing the information being requested. What should we have done? The dilemma – if we do not provide the information, the concerned family will be denied easy access to resources that enable them to protect their child. If we provide the information, we will invalidate future interview data from this family by adding a new element to the intervention. At a different level, if we feel compelled to make this information available to this family in the name of safety, aren’t we then jeopardizing the safety of children whose families are at hospitals under our usual care condition? Are we being inconsistent and unethical if we give the information to the requesting parent while also continuing the study, denying access to this information by parents who seek care at usual care facilities?
This presents interesting and significant research ethics issues in a public health context. The question both relates to the investigators’ safety-related obligations to participants, as well as questions of equity arising from the need for adequate controls as part of the research design. Here, as with most difficult questions in public health ethics, reasonable people of good conscience can likely disagree on the ultimate answer. Our view is that participant safety & wellbeing is sacrosanct and trumps all values related to the knowledge-making goals of a research protocol. This is especially the case where the populations involved in the study include care for members of vulnerable groups (i.e., children). Certainly any health care provider, and arguably any interviewer working on the research (even one who is not a health care provider) has a basic obligation to implement a low-burden intervention that could have significant health impact on a family.
The answer to the second question is more complex, and turns on whether it is acceptable to withhold a given intervention from the control arm of a study. Typically, the answer to this inquiry depends on the known efficacy of the intervention; if we know the intervention works, it is often unethical to run a controlled study in which that intervention will intentionally be withheld from a population for whom it is warranted. However, where the efficacy of the intervention is unknown, it is not clear whether withholding it exposes the participants in the control to any additional risk – after all, the intervention might not work – and therefore, the use of the control arm is considered ethically acceptable.
What ethical principles apply here?
There are obviously questions of social justice here – a principal goal of public health in the community is context balancing with ethics of autonomy in a patient care setting. In this public health study, one might argue that the good to the community is best served by choosing the path that preserves the integrity of the study over protecting the family because of the longer-term and farther-reaching implications for improving community health. However, with a serious potential consequence for the child and family, the ethics in the clinical environment favor assuring that the family has the information they are requesting so as to preserve their autonomy as decision-makers.
Because we don’t know yet if the intervention is effective, we must balance between the treatment of a given family in a clinical setting vs. the overall benefit to society in finding out what do we owe each other, and what do we owe the most vulnerable (e.g., children who may be powerless to make choices for themselves). Other values that seem to be relevant to the issues here include virtues like honesty, integrity, respect, courage, and trust and assuring both beneficence and nonmaleficence.
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