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Bangladesh Journal of Bioethics 2010; 1(3):15-21

ETHICAL ISSUES IN PUBLIC HEALTH RESEARCH

Abu Sadat Mohammad Nurunnabi1, Mahmood-uz-jahan2, Shaorin Tanira3

1.  Dr.  Abu Sadat  Mohammad  Nurunnabi,  Lecturer,   Department  of  Anatomy,  Dhaka  Medical  College, 
Dhaka. Email: shekhor19@yahoo.com. (Corresponding author)

2. Dr. Mahmood-uz-jahan, Deputy Director, Bangladesh Medical Research Council (BMRC), Dhaka.

3. Dr.  Shaorin Tanira, Coordinator (Health), MCH-FP Clinic, Manabik Shahajya Sangstha (MSS), Dhaka.

Abstract: Public health is the societal approach to protecting and promoting health. Public 
health  ethics  can  be  defined  as  the  identification,  analysis,  and  resolution  of  ethical 
problems arising in public health practice and research.  The emerging interest in ethical 
issues in public health research and practice reflects both the important societal role of 
public  health  and  the  growing  public  interest  in  the  scientific  integrity  of  health 
information and the equitable distribution of health care resources. This article provides an 
overview of ethical issues in public health research for young researchers and readers who 
do not necessarily have an in-depth knowledge of public health ethics. A framework of 
ethics analysis geared specifically for public health is needed to provide practical guidance 
for  public  health  professionals  and  researchers  in  Bangladesh.  Bangladesh  Medical 
Research Council is playing a role in setting a standard in the field of biomedical research 
including public health concerning its strategy and ethical issues and by helping different 
health  institutes  to build up a research environment.  Though public policy is based on 
many factors in addition to public health goals and ethical reasoning, it should not lead to 
the politically preferable option for a given time. 

Key words: Public health, Public health research, Ethical issues, National Health Research 
Strategy, Bangladesh Medical Research Council.

Introduction:  In 1923, the great public health scholar C.S. Winslow stated that public 
health  is  “the  science  and  art  of  preventing  disease,  prolonging  life,  and  promoting 
physical health and efficiency through organized community efforts”1. Public health is the 
societal approach to protecting and promoting health. Generally through social, rather than 
individual, actions, public health seeks to improve the well-being of communities2. Public 
health  activities  include  community  collaborations  and  partnerships  for  health  and  the 
identification  of  priorities  for  public  health  action. Recent  articles  have  included 
conceptual frameworks of public health ethics and overviews of historical developments in 
the field3,4. The emerging interest in ethical issues in public health research and practice 
reflects both the important societal role of public health and the growing public interest in 
the scientific integrity of health information and the equitable distribution of health care 
resources. Attention to ethical issues can facilitate the effective planning, implementation, 
and growth of a variety of public health programs and research activities5. Public health 

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mailto:shekhor19@yahoo.com


Bangladesh Journal of Bioethics 2010; 1(3):15-21

ethics,  which  can  be  defined  as  the  identification,  analysis,  and  resolution  of  ethical 
problems arising in public health practice and research, has different domains from those 
of medical ethics. Ethical concerns in public health often relate to the dual obligations of 
public health professionals to acquire and apply scientific knowledge aimed at restoring 
and protecting the public's health while respecting individual autonomy6. Amartya Sen, a 
Nobel winner economist,  emphasizes the importance of health to justice by saying that 
“health is among the most important  conditions of human life and critically significant 
constituent of human capabilities which we have reason to value”7.
Public health professionals must go through the steps of an ethics analysis to assure the 
public of their integrity.  The public must feel confident that public health professionals 
will offer only those proposals that will improve the health of the public, that proposed 
measures are minimally burdensome, and that a fair procedure has determined that the 
magnitude of the problem and the ensuing benefits  justify overriding conflicting moral 
claims8. Ideally, the government would set a public health policy which include research 
strategies, ethical concerns, priority of public demand, cost-benefit ratio and, of course, 
“by reference to scientific or objective knowledge,  maximizing the value of health and 
well-being within the population”9.

Moral  Reasoning  In  Public  Health:  Moral  reasoning  involves  ethical  questions  and 
reaching  a  decision  with  the  help  of  judgment  and  rational  analysis.  Among  different 
methods of moral reasoning, the following two are considered to be more pronounced5. 
1. Princple-based approach:
The principles  of beneficence,  nonmaleficence,  autonomy,  and justice,  as explained  by 
Beauchamp and Childress10, seek to reduce morality to its basic elements and to provide a 
useful framework for ethical analysis in the health professions. However, those principles 
do not provide a full philosophical justification for decision making. In situations where 
there is conflict  between principles,  it  may be necessary to choose between them or to 
assign greater weight to one. Practical problems in public health ethics require that these 
principles be made more applicable through a process of specification and reform11.
2. Case-based approach:
Sometimes, the specific decisions that emerge in particular cases may remain unaddressed 
by the principles. Such decisions are often made by focusing on the circumstances of the 
case at hand and the moral context in which the case rests. Case-based methods such as 
casuistry are grounded in analogical reasoning, appeal to paradigmatic cases, and practical 
judgment11,12. Here, decision making takes place at the level of the particulars of the case 
itself. Given a case and a particular decision to be made, maxims are identified that have 
bearing on the case.
Other approaches to moral reasoning, such as rights-based theories, duty-based theories, 
contractarianism,  ethics  of care,  narrative  ethics,  and communitarianism have not  been 
widely applied in public health5.

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Bangladesh Journal of Bioethics 2010; 1(3):15-21

Public Health Research: Ethical Concerns:  A framework for public health ethics will 
help public health professionals recognize the multiple and varied moral issues in their 
work.  Public  health  ethics  must  emphasize  positive  rights  as  well.  Public  health  has 
affirmative obligations to improve the public’s health, ensure ‘health for all’ and to reduce 
certain social inequities. Hence, a code of public health ethics is also needed to address 
such  social  justice.  Some  emerging  issues  related  to  ethical  aspects  of  public  health 
research are discussed below.
Ethical issues in public health surveillance:
Public health professionals have ethical obligations to both maximize the potential benefits 
of  routinely  collected  surveillance  and  disease  registry  data  and  minimize  risks  and 
potential  harms.  Steps  taken  to  assure  the  quality  of  data  collected  by  public  health 
surveillance  systems and disease registries maximize  the potential  benefits  of the data. 
Registry data must be accurate, complete, and timely5.
Minimizing risks and providing benefits:
Ethical concerns in epidemiology and public health practice often relate to the obligations 
of health professionals to acquire and apply scientific knowledge aimed at maintaining and 
restoring public health while respecting individual rights5. Potential societal benefits must 
often be balanced with risks and potential harms to individuals and communities, which is 
particularly  important  in  epidemiologic  studies  of  vulnerable  populations  e.g.  children, 
prisoners, old people, and populations that are socioeconomically disadvantaged13.
Obligations to communities:
These  obligations  include  communicating  the  results  of  public  health/epidemiologic 
studies at the earliest  possible time, after appropriate scientific peer review, so that the 
widest range of readers are able to get benefit from the information. Researchers should 
strive to carry out studies in a way that is scientifically valid and interpret and report the 
results of their studies in a way that is scientifically accurate and appropriate5. Moreover, 
they should respect cultural diversity in carrying out studies and in communicating with 
members of affected communities14.
Informed consent, privacy and confidentiality:
Informed consent provisions in public health studies ensure that research participants will 
make a free choice and also give institutions the legal authorization to proceed with the 
research15. This includes the purpose of the research, the scientific procedures, anticipated 
risks and benefits, any inconveniences or discomfort, and the participant's right to refuse 
participation or to withdraw from the research at any time. Seeking and updating informed 
consent is fundamental to good practice in research involving human participants16. Special 
considerations  for  obtaining  informed  consent  may  arise  in  public  health  studies  of 
socioeconomically deprived people. People who have limited access to health care may 
misunderstand an invitation to participate in a study as an opportunity to receive medical 
care.  In  addition,  they may be  reluctant  to  refuse participation  when the  researcher  is 
viewed as someone in a position of authority, such as a physician or university professor. 
Socioeconomically deprived people may also be more motivated to participate in studies 
involving financial incentives for participation17. A further issue is that there is often a need 
to translate informed consent statements into a language other than English18. 

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Bangladesh Journal of Bioethics 2010; 1(3):15-21

Another important way in which public health researchers reduce potential harms and risks 
to  participants  in  research  is  by  protecting  the  privacy  of  the  participants  and  the 
confidentiality  of  their  health  information19.  Specific  measures  taken  by  researchers  to 
protect the confidentiality of health information include keeping records under lock and 
key,  limiting  access  to  confidential  records,  discarding  personal  identifiers  from  data 
collection forms and computer  files whenever feasible,  and training the staff  about the 
importance  of  privacy  and  confidentiality  protection20.  Other  measures  that  have  been 
employed to safeguard health information include encrypting computer databases, limiting 
geographic detail, and suppressing cells in tabulated data where the number of cases in the 
cell is small21.
Avoiding and disclosing conflicts of interest:
Other ethical issues that arise in the professional practice of epidemiology relate to how to 
deal with potential conflicts of interest, in order to ‘maintain public trust in epidemiology 
and sustain public support for health research’22,23. Conflicts of interest can affect scientific 
judgment and harm scientific objectivity16. Studies have suggested that financial interests 
and  researchers’  commitment  to  a  hypothesis  can  influence  the  reported  research 
results23,24. Hence, researchers should disclose financial  interests and sources of funding 
when publishing research results. It may also be important to disclose information about 
potential  or actual financial  conflicts  of interest  when obtaining informed consent from 
research participants. 

The  Role  Of  The  Institutional  Ethical  Review  Committee  (Erc):  The  purpose  of 
research ethics committees or institutional ethical review committees (ERCs) is to ensure 
that studies involving human research participants are designed to conform the relevant 
ethical standards and that the rights and welfare of participants are protected25. Research 
ethics committees should not function under political control or one’s sweet will26. Ethics 
committees must be independent of research organizations. This independence relates to 
their decisions, not their operating processes16. A methodical review by such committee 
ensures that studies have a “favorable balance of potential benefits and risks, and that the 
participants are selected equitably, and that procedures for obtaining informed consent are 
adequate”27. It is praise-worthy that National Institute of Preventive and Social Medicine 
(NIPSOM),  all  the  government  medical  colleges  and  different  specialized  government 
health  institutes  have  got  their  own  ethical  review  committees  (ERCs).  Moreover, 
Bangladesh Medical Research Council (BMRC), the focal point for health research in the 
country,  has  got  a  strong ‘National  Research  Ethics  Committee’  to  review the  ethical 
aspects of a research project28.
The first and foremost addressed issues are informed consent, privacy and confidentiality 
of data, risk-benefit ratio of the community/participants29. Other issues concerned in the 
guidelines include those pertaining to scientific misconduct, intellectual property and data 
sharing,  publication  of  research  findings,  and  cross-cultural  or  international  health 
research30. However, any research now requires only a single ethical review, irrespective of 
the authority concerned (but preferably done by the parent institution) and number of sites 
involved.  What  is  needed  in  our  country  is  that  all  research  ethics  committees  in 

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Bangladesh Journal of Bioethics 2010; 1(3):15-21

Bangladesh should operate in a standard fashion, providing an impartial, unbiased review 
and  quick  decision.  Directorate  General  of  Health  Services  (DGHS),  Bangladesh  has 
already published a ‘National  Health Research Strategy’  with technical  assistance from 
Bangladesh Medical Research Council (BMRC) and World Health Organization (WHO) 
featuring different aspects of biomedical research which include institutional framework, 
priority  setting,  ethical  clearance,  financing,  monitoring  and  evaluation,  capacity 
development, dissemination and utilization of research results31.  
 

Conclusion: Bioethics, as a discipline, helps health care professionals identify and respond 
to moral dilemmas in their work. Public health is what we, as a society, do collectively to 
assure the conditions  for people to  be healthy1.  Hence,  a framework of ethics  analysis 
geared  specifically  for  public  health  is  needed,  both  to  provide  practical  guidance  for 
public health professionals and to highlight “the defining values of public health, values 
that differ in morally relevant ways from values that define clinical practice and research”8. 
Besides, conflict of interest of the researchers, indemnity for the protection of participants, 
and  confidentiality  of  data  are  widely  accepted  as  core  ethical  issues  in  any research. 
Therefore,  we  should  look  into  these  matters  seriously  in  the  field  of  public  health 
research. Of course, public policy is based on many factors in addition to public health 
goals and ethical reasoning, but it should not lead to the politically preferable option for a 
given time. 

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