150406P - ETHICS OF PUBLIC HEALTH AND HEALTH PROMOTION

Presentation at a training program ‘Applying the Principles of Ethics to Clinical Practice:’ held at Aramco Dhahran April 6, 2015 by Professor Omar Hasan Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Ethics Committee King Fahad Medical City.

Concept of good health

• Health is a positive state of being and not just absence of disease. Individuals who are disease-free may not be healthy.
• The components of good health are spiritual health, physical health, psychological and mental health, and social health.
• Islam looks at health in a holistic sense.
• If any part of the body is sick the whole body is sick
• If a member of a family is sick the rest of the family are affected emotionally and psychologically.
• Any sickness in the community will sooner or later have some negative impact on all the members.
• The holistic outlook also means that physical, emotional, psychological, and spiritual health are considered together.

Concept of illness

• Definition of disease considers several dimensions that may operate singly or in combination: moral or spiritual, biological or pathological, psychosocial, or normative statistical.
• Overall disease is a state of dis-equilibrium, khuruuj al badan ‘an al i’itidaal.
• A distinction must be made between disease as a pathological manifestation and illness that is a subjective feeling.
• There is a 2-way interaction between diseases of the heart, amradh al qalb, and diseases of the body, amradh al badan.
• The Islamic position is to approach most diseases empirically and to be guided by experimental science.
• Islam rejects superstitious beliefs and practices in all their various forms and manifestations.

Concept of family health

• A healthy family promotes the health of all its members. There is no alternative to the family for child up-bringing. The family teaches trust, loyalty, a sense of belonging, and rights and responsibilities.
• It is an economic unit.
• It is the main source of primary health care.
• It is a source of calmness and tranquility.
• Threats to the family are extra-marital sexual relations, neglect of family duties in pursuit material goods, extreme individualism and self-interest, and bad socio-economic circumstances.
• Dysfunctional families are not healthy in the physical and psychological sense and have long-term impact on the children.
• The causes of family dysfunction are multiple: economic pressures, a hedonistic life-style, and decline of moral and religious values in the society.

Concept of community health 1

• Private and public efforts of individuals, groups, and organizations to promote, protect, and preserve the health of those in the community.
• Involves community development, community organization, community participation, and community diagnosis. Community health is affected by physical factors (geography, the environment, community size, industrial development, socio-cultural factors (beliefs, traditions, prejudices, economic status, politics, religion, and social norms, individual behavior, and community organization.
• Whereas public health is government-driven, community health is community-driven. Communities both in pre-history and the historical era undertook measures to protect health.
• Before the 1980s emphasis was on public health. After that the importance of community health and community participation were recognized.

Concept of community health 2

• The Qur’an has described good and bad communities in the past. It described communities that were punished or destroyed by Allah sue to moral deviations. No community is destroyed or is punished until it receives a warning from Allah.
• Community diagnosis is identifying and describing health problems in a community with a view to initiating public health interventions.
• Many communities are unhealthy in the physical and social or mental sense.
• Underlying causes of poor community health are social and moral such as social injustice, immorality, sexual promiscuity, over-nutrition, and addiction to alcohol and drugs.
• Community health can be improved by having healthy individuals in the community, fulfilling communally obligatory functions, and establishing mutual cooperation and mutual complementation.

Concept of preventive medicine, tibb wiqa’i:

• Preventive medicine, tibb wiqa’i, is covered under the Qur’anic concept of wiqayat. Prevention is therefore one of the fixed laws of Allah in the universe and its application to medicine therefore becomes most obvious.
• The concept of prevention, wiqayat, does not involve claiming to know the future or the unseen, ghaib, or even trying to reverse qadar. The human using limited human knowledge attempts to extrapolate from the present situation and anticipates certain disease conditions for which preventive measures can be taken.
• Only Allah knows for sure whether the diseases will occur or not. The human uses knowledge of risk factors for particular diseases established empirically to predict disease risk. Preventive action usually involves alleviation or reversal of those risk factors.

Concept of health promotion

• Most diseases can be prevented using spiritual approaches. These involve aqiidat, ibadat, avoiding haram and promoting halaal.
• Spiritual promotion at the community level involves enjoining the good and forbidding the evil.
• Physical health promotion at the individual level includes immunization, good nutrition, personal hygiene, and disinfection.
• Physical promotion at the community level involves environmental sanitation.
• Health promotion involves pro-active measures that make health better such as exercise, good nutrition; adequate rest; mental calmness; tranquility of family life, iman and spiritual calmness.

Ethical issues in screening

• The benefit of screening must outweigh the harm
• The efficacy of screening must be proved in a proper trial
• Confidentiality must be maintained
• Informed consent must be obtained.

Ethical issues in vaccination

• Autonomy vs compulsion
• Mass immunization of children
• Mass immunization in epidemics
• Individual risk vs public benefit (concept of herd immunity)

Ethical issues in infectious disease control

• Isolation, quarantine
• Compulsory treatment / immunization
• Notification (confidentiality)
• Contact tracing

Ethical issues in addictions

• Personal autonomy vs public interest
• Restriction of smoking
• Passive smoker
• Society bears costs of treating diseases
• Drug addiction: criminal vs victim

Ethical issues in disasters

• Triage: who has priority
• Short term vs long term
• Medical intervention vs respect for local culture and customs

Ethical issues in health economics

• Monetary value of human life and human life
• Equity: access, accessibility, coverage, quality
• Public vs private
• Subsidizing unhealthy life styles

Case scenario 1

A prospective couple who are first cousins refused to submit themselves to pre-marital genetic screening and preferred to take the risk of producing children with genetic defects. The Ministry of Health insisted that they buy long term health insurance to cover life-time complex medical treatment for up to 5 children

Case scenario 2

A pediatrician living and practicing in an exclusive high class area refused to take his children for measles vaccination arguing that the risk of immunization complications was higher than the risk of getting measles. He had not seen or heard of a case of measles in the community in the past 10 years.