phasic 7 quiz 3
Review the 8 steps of the Nuffield Council on Bioethics Intervention Ladder.
1. Do nothing 2. Provide information 3. Enable Choice 4. Guide choice by changing the default policy 5. Guide choice by incentives 6. Guide choice by disincentives 7. Restrict choice 8. Eliminate choice
To impose Quarantine or Isolation on a person what are the basic requirements of Due Process?
1. Reasonable basis for detention 2. Least restrictive means 3. Right to notice 4. Right to counsel 5. Right to a hearing upon request
Courts, legislatures, and executive agencies that exercise authority relating to public health are obliged to adhere to what requirements?
1. substantive requirements set by law 2. procedural requirements set by law
What is the age at which the sale of tobacco products is permitted in the United States? And, what law determined that age.
21, and the consolidated appropriations act of 2020
What' s a nudge?
A "Nudge" is any aspect of the choice architecture that alters people's behavior in a predictable way without forbidding any options or significantly changing their economic incentives
The textbook lists four of the ten great public health achievements of 1900 through 1999. What is the relationship between these achievements and the source of the authority of public health entities?
Achievements: control of infectious disease, motor vehicle safety, fluoridation of drinking water, recognition of tobacco use as a health hazard. In all of these cases, the states and local governments used their police power to achieve these public health goals.
What clause in the Constitution has been interpreted by the Courts to allow the Congress to regulate interstate commerce to prohibit intrastate cultivation and use of controlled substances such as illegal drugs?
Article 1, section 8, clause 3
Jacobson v. Massachusetts (1905)
Autonomy issue, Jacobson refused to be vaccinated for smallpox and was asked to pay $5 fine He felt this deprived him of his liberty under 14th amendment Can negatively affect rest of community
Why did the original Bill of Rights not apply to the States and what happened to change that?
Bill of Rights was applied federally, so the 14th amendment specified that the Bill of Rights applied to all states
What process in the American political system and law that puts limits on the activities of the President, the Congress and the courts
Checks and balances The President Congress has power to impeach the president, senate approves appointments Judicial branch can determine President's executive actions as unconstitutional The Congress President has the power to veto Judicial branch can declare certain laws unconstitutional The Courts President has the power to appoint judges Senate approves court appointments, also has power to impeach
City of New York v. New Saint Mark's Bath (1986)
City closed bathhouses on grounds that they contributed to AIDS crisis Health department has authority to close bathhouses/other establishments if deemed enough of a public health risk Could have been alternative ways to decrease issue: HIV education and testing in bathhouses, mandate condom use, no more individual stalls
What are the differences among the concepts of dual sovereignty (also known as concurrent powers), federal supremacy and preemption?
Dual sovereignty: refers to powers shared between state and federal government Federal supremacy: state laws have to yield to federal laws Preemption: general rule that superior government can block or limit inferior government's authority: federal, state, local
Name two cases that dealt with the question of due process, [Slides 89, 90] and two cases that dealt with the issue of equal protection.
Due process: Souvaraneth vs Hadden (2002): TB patient sent to jail Greene v Edwards- rigorous due process before individual w infectious disease can be confined Equal Protection: Jew Ho v Williamson (1900): Bubonic plague quarantine covering only China Town District Craig v Boren: different age limits on selling beer to males v females
What "powers" in public health are attributable to the states, what powers are attributed to the Federal government and how are those powers derived?
Enumerated powers Derived from the U.S. Constitution, explicitly stated in Constitution, federal government has these powers Implied Powers Not explicitly stated in the Constitution, powers necessary to carry out expressed powers, Federal government Concurrent Powers Applied to both federal and state, (collect taxes, build roads, establish bankruptcy laws, spend money)
What was the Portion Cap Rule?
Food service establishments would cap size of cups/containers for sugary beverages at 16 oz Exceptions: alcoholic beverages, shakes/smoothies, mixed coffee drinks, mochas, lattes, and 100% juice drinks Applied to restaurants, delis, fast-food franchises, movie theatres, stadiums, and street carts Didn't apply to grocery stores, convenience stores, corner stores, and gas stations
What amendment to the Constitution addressed the issue of freedom of religion?
In the Bill of Rights, the 1st Amendment grants freedom of speech, religion, and right to assembly
DeShaney v. Winnebago County Dept. of Social Services (1989)
Joshua Deshaney returned to father by department of social services after reports of abuse, and he ended up being brutally beaten and permanently injured Argument that social workers should have acted to protect the boy and not return him to an abusive father Supreme court believed the issue should be handled by the state
What is the basic distinction between formal justice and material justice,
Formal justice criterion is to treat equals equally, or similar cases similarly. This does not specify the relevant respects in which people must be equal or cases similar. Nor does it indicate how those who are equal in relevant respects should be treated, only that they should be treated equally. Formal justice is the impartial, consistent and strict application of established rules or laws. Formal mechanisms derive their structure and power from the laws, policies, and regulations made by the government. They operate as a part of the government and are funded by the state. Their function is to interpret and resolve conflicts about the laws, as well as determine responsibility for violations of the laws. In federal systems, formal justice mechanisms may also derive from the power of a specified federal entity within the nation-state. Examples of material criteria include to each accord ing to his/her need to each according to achievement, to each according to effort*, "to each according to ability to pay,"and soforth. These and other materialcriteria are defensible in certain contexts but not other.The just distribution of grades in anacademic course should track students' achievement, rather thantheirneedortheir ability to pay.
Taxing and spending serves what purpose for public health at the federal level?
Fund services and activities designed to ensure public health and safety, can also be used to regulate the behavior of individual (think taxes on cigarettes).
What immunization example did Childress use to elaborate on the principle of Utility? What statistical presumption was used to determine whether immunization should be gender specific or not?
HPV
Jew Ho v. Williamson (1900)
If quarantine orders for Bubonic plague in San Francisco were reasonable and not discriminatory, as quarantine only covered the China Town District Court found that the quarantine was discriminatory, putting burden on a specific ethnic population
The text asserts that public values are examined and legal and ethical justifications are offered about what that constitutes legitimate use of government authority in which two places?
In legislatures (provide public forums for debates about legislation and government activities) and in court proceedings (parties provide their argument about laws or government actions that are in dispute).
What are the justificatory conditions that can be used to restrict or eliminate autonomous choices and actions, including liberty of action?
In some circumstances, coercive and other measures that restrict or eliminate individuals' choices in the name of public health can satisfy the justificatory conditions of effectiveness, necessity, least infringement, proportionality, and impartiality in the context of public justification
Souvannarath v Hadden (2002)
Laotian TB patient in jail due to quarantine and isolation order Multidrug resistant TB: was sent a notice that didn't state reason for detention in English, which she spoke very little of Didn't comply with medications from chest clinic, and was not informed why she was being detained when she didn't show at clinic In jail for 3 days, handcuffed, harassed, chained Violated individual liberties
According to the CDC Public Law Program, what is the distinction between law and ethics in Public Health?
Laws -- Provides authority, limitations on state power, incentives and disincentives for behavior, often allows for much professional discretion. Ethics -- : Provides ongoing analysis, deliberation about, and justification for public health action and policy, often when law is indeterminate.
Craig v. Boren (1976)
Male contested that age limits for purchasing beer were discriminatory towards males Reasoning: 18 to 20 year old men are at higher risk for alcohol related car crashed than females Issues: does involve creating different sets of rules for different groups, which is often unethical
Is it a violation of due process to detain a person for isolation or quarantine before they have a hearing?
No, it is not a violation of due process to detain someone for isolation before a hearing if public health is jeopardized. State laws allow for detention before a hearing, but it does not eliminate the right to a hearing.
Which Supreme Court Case concluded that Parental authority is not absolute and can be permissibly restricted if doing so is in the interests of a child's welfare, and that that the government has broad authority to regulate the actions and treatment of children
Prince v Massachusetts (1944)
What is the nature of police power for a public health agency?
Provides surveillance, helps with reporting and epidemiologic investigation, enforces vaccination, isolation/quarantine, treatment, and property evacuation Can designate health hazards as public nuisances, and use power to shut down Pass laws regulating public health hazards: traffic laws, tobacco use laws
Which two cases in the case law set involved disparate treatment of persons of Asian heritage?
Souvannarath v Hadden (2002) TB patient incarcerated Was not told the reason for her detention, was not informed why she was being detained Jew Ho v Williamson (1900) Quarantine over San Francisco's Chinatown district during the bubonic plague Quarantine order was not reasonable and discriminatory because the orders targeted the Chinese population only
Review the sources of US law on Table 3.1 What is the difference between statutes and regulations, and why is that important to a public health authority?
Statutes come from congress and state legislatures, while regulations involve legislators giving agencies the power to enact regulations similar to statutes Regulations can be more specific to situations, and can be put into action more quickly: helpful for local issues or more technical issues
New York Statewide Coalition of Hispanic Chambers of Commerce v. New York City Department of Mental Health and Hygiene (2013)
Struck down portion cap rule: food service establishments cap size of cups and containers for sugary beverages at 16 oz Lots of written comments mostly in support, but some against There were exceptions: didn't include, alcohol, shakes/smoothies, some coffee drinks, 100% juice drinks; didn't apply to grocery/convenience stores, corner markets, gas stations
As traditionally understood, what authority over public health does the Constitution convey to the federal government?
The 10th Amendment of the Constitution says that all powers not delegated to the federal government go to the states. Under the 10th Amendment, states retain the primary responsibility for protecting the public's health; this is a part of the State's Police Powers.
What amendments to the Constitution address the issue of Due Process
The 5th and 14th amendments address the issue of Due Process and state that the government cannot deprive people of life, liberty or property without acting fairly and reasonably.
What amendments to the Constitution address the issue of Equal Protection
The 5th and 14th amendments address the issue of Equal Protection as the government shall not "deny to any person within its jurisdiction the equal protection of the laws
What are the harshest criticisms of CBA?
The attempt to translate the range of possible goals and benefits being sought into dollar figures. It appears to reduce what is valuable an valued to dollar amounts-even to state the value of life in monetary terms-and thus to screen out much that is important in public health as well as in the society at large.
There is an important weakness in argument that when governments addressed tobacco related problems and used civil litigation to recoup funding for healthcare costs and related tobacco control activities, despite public deliberation and leadership. What is that weakness
The total revenue collected was $243.8 billion, and CDC's best practice recommended funding of $29.2 billion, but only $8.1 billion was actually used: made a larger profit than needed, and still spent less than recommended for positive interventions
Review the Sources of US Law
U.S. Constitution Federal Government State governments Local governments Statues (enacted by Congress, give power to executive branch agencies such as health departments) Regulations (legislatures give agencies power to make regulations that have same power has statues)
What are the two Questions Bernheim and Bonnie consider fundamental to discussions of the government's role in public health?
What is the source and scope of legal authority, if any, and what rules or legal principles constrain the use of this authority Are there relevant legal and ethical cases or precedents that should be taken into account?
Name four governmental actions that are, in effect, a law.
a piece of legislation, a regulation, a decision made by a judge, an executive order
Childress settles on how many general moral considerations (GMCs)?
a. 9 b. They refer to GMCs sometimes as norms, principles, or values, and occasionally as rule.
Distinguish between having privacy and having a right to privacy
a. A person may have privacy without having a right to privacy, that is, a justified claim against others that they not infringe that person's privacy. b. Conversely, a person may have a right to Privacy but still lack privacy if others violate that right. c. Many factors may determine whether a person has privacy—perhaps others are indifferent to her or have no effective way to access her, or perhaps they respect her enforceable right to privacy. d. Whatever the reason for a person's state or condition of limited access, that person has privacy whether or not she has a right to privacy.
Confidentiality, what is it:
a. Confidentiality overlaps with informational privacy—both involve limited access to information about a person. b. While informational privacy has a more recent pedigree, emerging a little over a century ago, confidentiality is arguably one of the oldest and most prevalent rules in medical ethics. c. Confidentiality can be viewed as a way to protect informational privacy within a specific set of relationships. d. In a confidential relationship in healthcare, the information generated about a patient is protected within limits by rules of confidentiality. e. A patient has reasonable and legitimate expectations that the information generated in this relationship will not be disclosed to others without their consent or authorization.
A person is said to be coerced if: (1) they faced narrowed, constricted options, and (2) others' purposeful actions created the situation of narrowed, constricted choices. Give examples:
a. Confinement of a person who is not complying with therapeutic requirement b. Threaten confinement if the person does not comply
What is the difference between CEA and CBA? Which appears to be more important in Public Health?
a. Cost effectiveness analysis (CEA) and cost benefit analysis (CB) b. CEA states the benefits it measures in various ways. For instance, public health officials might use measures such as years of life (life-years or Lys), quality-adjusted life-years (QALYS), number of cases prevented, or number of persons screened for the outcomes of its programs and interventions. i. CEA eschews the use of money in stating the benefit that is being balanced against costs. ii. Public health officials can use CEA to compare public health programs or interventions only if they have the same endpoint, such as life-years saved. 1. Not possible to compare different public health programs or interventions if their endpoints are different. iii. CBA attempts to restate benefits in ways that will facilitate a direct comparison between the benefits and the costs as well as between different programs and interventions that may have different outcomes such as saving life-years or reducing days lost from work.-
1. Under the principle of utility name the two formal analytic tools used to maximize social welfare.
a. Cost-effectiveness analysis (CEA) b. Cost-benefit analysis (CBA)
What is the basic distinction between distributive justice and procedural justice
a. Distributive justice—distributing benefits and burdens fairly b. Procedural justice- ensuring public participation, including the participation of affected parties.
Philip has tuberculosis, and it is recommended that he have directly observed therapy (DOT), based on the Intervention Ladder , what can be done to facilitate his compliance with DOT.
a. Guide choice by incentives----money for transportation b. Guide choice by disincentives—threaten isolation c. Eliminate choice—isolation and medication
What are the three stages of Risk Assessment?
a. Identifying risks i. Locating dangers or threats, for instance, of an outbreak of a deadly avian influenza b. Estimating the risk i. Determining to the greatest extent possible, the probability and the magnitude of the harms associated with the dangers c. Evaluating the risk i. Determined whether the identified and estimated risks are acceptable ii. Risk is an inherently probabilistic term, whereas benefits need to have qualifiers
What are the dimensions of privacy?
a. Informational Privacy b. Physical Privacy c. Decisional Privacy d. Proprietary Privacy e. Relational Privacy
What are the criticisms of CEA
a. It tends to focus on the costs and benefits that can be measured fairly easily. Ethically, It is important to attend to the range of relevant benefits and costs in conducting analyses of programs and interventions. b. CEA's based on QALYs may discriminate against older persons because, an intervention that prevents the death of younger people will probably produce more QALYs than an intervention that prevents the death of older people. c. Other important factors in decision making in public health include notions of justice, equity, personal freedom, political feasibility, and the constraints of current law.
List and define four theories of distributive justice
a. Libertarian i. Influenced by such Philosophers as John Locke and Robert Nozick ii. Focuses on. individuals' liberties, and emphasizes the duties to respect others' liberties and the state's duty to protect the liberties, conceived as rights, of its citizens when they are threatened. iii. This view leads to a conception of the "minimal state," sometimes called the "night watchman state," designed to prevent or punish transgressions of individual boundaries., including individuals' property rights. iv. Taxation is generally opposed as an unjust violation of liberty rights, especially if it goes beyond what is necessary for the minimal state to protect liberty rights. v. In this view, health care is not a right, but people may voluntarily choose to act charitably and contribute to health care for others and may within a community even voluntarily consent to some form of healthcare distribution. vi. Public health may be against contagious diseases—a form of boundary violation— rather than on broader conceptions of health promotion that mark much contemporary public health. b. Utilitarian i. Utilitarian theories of justice historically shaped by such figures as-Jeremy Bentham and John Stuart Mill, ground conceptions of justice in the principle of utility, which requires actions, policies, or rules that produce maximal net benefits. ii. According to Mill, " justice is a name for certain moral requirements, which. stand higher in the scale of social utility, and are therefore of more paramount obligation, than any others; though particular cases may occur in. which some other social duty is so important, as. to overrule any one of the general maxims of justice." iii. Justice, which involves correlative duties and rights, is not independently warranted but is rather derivative from utility. 1. In this framework, duties and rights in just health care or just public health presuppose a foundation in net social utility. 2. Health care and public health can be valued at least to the extent that they contribute to net social utility. 3. justice has to do with the way that tangible benefits and burdens are assigned, and not with the happiness or unhappiness that the assignees experience. c. Egalitarian i. Egalitarian theories of justice draw on philosophical and religious perspectives that recognize the. equality of persons in at least some respects and the importance of treating them as equals in certain respects. ii. Although there are a number of different versions of egalitarian theories, many of those in the, last several decades have been influenced by the magisterial theory of justice propounded by John Rawls. iii. These generally recognize equalities in certain basic social goods but allow for other inequalities as well, and most of them recognize the possible legitimacy of a two-tiered system, with the lowest tier being a decent minimum or adequate level of health care (to be set in a deliberative democratic way). iv. Norman Daniels, building on Rawls conception of "fair equality of opportunity argues that justice requires a society to remove or reduce obstacles that prevent fair equality of opportunity. 1. This includes providing programs that compensate for persons' disadvantages such as their health disadvantages. d. Communitarian i. Communitarian theories of justice, drawing on a number of philosophical perspectives, do not assign independent significance to individual rights, such as liberty, in contrast to libertarians (and to proponents of egalitarian justice). ii. Their conception of just health care and public health depends on the community's conception of the good of health, in relation to other goods, and the contributions of health care and public health to all those goods, not simply to health. 1. Daniel Callahan approaches the allocation of health care from a putative shared substantive consensus about the good society. Hence, his questions for judging just allocations in health care and public health focus on their contributions to a good society: Just what is it that good health brings to a society and how much and what kind of it are necessary for a good society. iii. This approach resonates with public health ethics», in viewing the community as both a source of insight into values and as a target (beyond the aggregation of individuals)' for just health care and public health
List six criteria that Pesik et al believe should be considered for allocating scarce resources following a terrorist attack:
a. Likelihood of benefit b. Effect on improving quality of life c. Duration of benefit d. Urgency of the patient's condition e. Direct multiplier effect among emergency caregivers f. Amount of resources required for successful treatment
What are the categories of Social Utility discussed in the Text?
a. Narrow social Utility b. Broad social utility
Name two characteristics of paternalist interventions.
a. Paternalistic actions have two characteristic features: b. (1) they aim to protect or promote the welfare of individuals themselves ( rather than others or the society), and c. ( 2 ) they seek to accomplish this goal by overriding some of the individuals' choices and actions.
What are the three considerations that Childress subsumes under the rubric Utility
a. Producing benefits in conjunction with other connected moral considerations b. Avoiding, preventing, and removing harms c. Producing the maximal balance of benefits over harms and other costs.
Why is public trust in public health decisions important?
a. Public's right to justification of the publicly articulated reasons for triage decisions and public participation in the process of setting allocation standards and procedures b. Building and maintaining public trust is foundational to public health ethics c. What will and will not be accepted by our communities will depend upon whether people understand the basis for the schemes employ and whether they agree with the ethics therein.
Norman Daniels argues that fair process, a form of procedural justice, arguing: "the moral legitimacy of limits and priorities involves not just who has moral authority to set them, but how they are set." What are his criteria of a fair process?
a. Publicity Condition b. Relevance Condition c. Revisability and Appeals Condition d. Regulative Condition
Under what circumstances can financial incentives be deemed coercive?
a. Some view incentives as potentially coercive, while others view them as expanding options. b. If the incentive is too low, it may be exploitative c. If the incentive is too high, it may be an undue inducement
What is the distinction between strong paternalism and weak paternalism?
a. Strong Paternalism: b. The intended beneficiary is a person who is considered to be autonomous or substantially autonomous but whose choices and actions put him or her at risk. Such actions infringe the intended beneficiary's autonomy, and, hence, are at least presumptively wrong c. Paternalistic interventions are disrespectful, demeaning and insulting to the beneficiary whose autonomy they violate d. Hard to justify taking the final three steps of the Intervention Ladder, as they most compromise autonomy e. Libertarian paternalism accepts interventions from rung 1 through 5, as they leave the individual free to resist and which can be easily justified even for paternalistic reasons. Weak Paternalism: • The intended beneficiary is considered to be nonautonomous or substantially nonautonomous - May have significant mental deficiencies, serious psychiatric problems, drug addiction, etc. • Their choices and actionsdo notwarrant therespectand noninterferencethe autonomouspersoncanclaim • Justice, fairness and public beneficence warrant intervention a. It is not easy in public health practice to determine when people are substantially nonautonomous and when they can be coerced for their own benefit
How does Childress distinguish the principle of utility from Utilitarianism?
a. The principle of utility is understood as the principle of producing the maximal balance of good over bad effects or maximum net benefits. b. Utilitarian tend to make utility the foundational principle from which all other moral norms are derived or the dominant principle that overrides all other moral consideration.
What is the difference between isolation and quarantine?
isolation: separate sick people with contagious disease from people who aren't sick quarantine: separates and restricts movement of people exposed to contagious disease to see if they become sick
Given that the government has broad authority to regulate the actions and treatment of children, what form of paternalism covers that authority?
weak paternalism, at least for young kids
In public health and health the words distribution, micro allocation, selection, triage and rationing refer to what?
• These Severaldifferent terms havebeen usedto describeand directthe process of distributingscarce preventive, prophylactic , and therapeutic resources in a public healthcrisis.Theseincludedistribution, (micro) allocation, selection,triage, rationing, and the likeeeeeee • Triage usually implies systematic "rationing"usingclassificationsandcategoriesthatareeffortsto "do the usedtodescriberationingmedicalandothergoods in military contexts, civilian emergency responses-for example, toearthquakesoramasscasualtyshooting and in emergencyunits inhospitals.Asystemoftriage gradespeopleaccording to needs_andprobableoutcomes,and it seeksto maximize utility.
