Submitted by Joel L. Nitzkin, MD
As I see it, ethical issues usually present to public health staff, not as ethical issues, but in terms of budget, or potential conflict with elected officials or external stakeholders. My impression is that the usual response is to simply see the unethical policy or limitation as something you cannot do anything about, simply give in to it, and do the best you can within the limitations imposed. Such a stance is usually good for ones continuing employment and relations with major stakeholders, but bad for the health of the public. Perhaps some of the following could serve as introduction to meaningful discussion as to better address these ethical conundrums.
1. Vaccine: an excellent case could be made for adding meningococcal vaccine for entering college students and for the shingles vaccine for seniors to the list of vaccines that health departments both recommend and provide at no cost or low cost to those needing them. The issue here is cost -- and how one considers the costs, and benefits in the context of our currently fiscally constrained environment.
2. Truth that conflicts with deeply held beliefs of both the public and most stakeholders involved with tobacco control: The research has now been completed with shows, quite definitely that the smoke-free products currently on the American Market (chewing tobacco, snuff, snus, etc) poses no increased risk of any form of cancer, no increase in heart disease and possible very small increase in risk of stroke, when compared with non-users of tobacco. The nicotine, per se, however, does pose an increased risk of prematurity when used by pregnant women, but none of the other hazards of smoking in pregnancy (miscarriage and birth defects). It does not even cause or increase the risk of tooth or gum disease. These findings directly conflict with three of the four mandated warnings for smoke-free tobacco products, now required by law (not a safe alternative to smoking, causes mouth and throat cancer, causes tooth and gum disease). Only the warning that the product is addictive is technically valid.
The most current summary of the science behind the statements noted above is in the July 2011 review by Brad Rodu, posted on the Tobacco page at www.aaphp.org
For the sake of the ethics discussion, accepting all of the above as true (because most will want to deny the truth of these statements because they conflict with longstanding tobacco control policy and dogma) -- the following questions arise:
2a. Should AAPHP, either directly or through the AMA, petition the federal government to delete or otherwise modify the technically incorrect warnings.
2b. At the local level, being aware of the facts as noted above, should local or state public heath agencies communicate this information to the general public and advise them that the currently mandated warnings are technically incorrect?
2c. Is deliberately lying to or otherwise misleading the general public ever ethically justifiable. If so, under what circumstances?
Since it appears that I will not be able to attend this year's APHA meeting, I would be very interested in whether the items above are brought up for discussion, and, if so, a summary of the opinions and conclusions discussed.
Joel L. Nitzkin, MD