Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 1 ORIGINAL RESEARCH A code of ethical conduct for the public health profession Ulrich Laaser1,2, Peter Schröder-Bäck3,4 Eliudi Eliakimu5, Katarzyna Czabanowska3,6, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030)7 1 Faculty of Health Sciences, University of Bielefeld, Bielefeld, Germany; 2 Institute of Social Medicine and School of Public Health and Management, Faculty of Medicine, University of Belgrade, Belgrade, Serbia; 3 Department of International Health, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Science, Maastricht University, Maastricht, The Netherlands; 4 Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany; 5 Health Services Inspectorate and Quality Assurance Section, Health Quality Assurance Division, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania; 6Faculty of Health Sciences, Medical College, Jagiellonian University, Krakow, Poland 7 George Lueddeke, Think-Tank Convenor/Chair; Southampton, United Kingdom; Membership of the “One Health Global Think-Tank for Sustainable Health & Well-being (GHW 2030)”: Moaz Abdelwadoud, Ibukun Adepoju, Muhammad Mahmood Afzal, Muhammad Wasif Alam, John Ashton, Vesna Bjegovic-Mikanovic, Bettina Borisch, Genc Burazeri, Sara Carr, Lisa Conti, Katarzyna Czabanowska, Eliudi Eliakimu, Kira Fortune, Luis Galvão, Iman Hakim, N.K. Ganguly, Joshua Godwin, James Herington, Tomiko Hokama, Howard Hu, Ehimario Igumbor, Paul Johnstone, Mitike Getnet Kassie, Laura Kahn, Bruce Kaplan, Gretchen Kaufman, Daniella Kingsley, Ulrich Laaser, Joann Lindenmayer, George Lueddeke, Qingyue Meng, Jay Maddock, John Middleton, Geoff Mccoll, Thomas Monath, Joanna Nurse, Robert Otok, Giovanni Piumatti, Srinath Reddy, Helena Ribeiro, Barbara Rimer, Gautam Saha, Flavia Senkubuge, Neil Squires, Cheryl Stroud, Charles Surjadi, John Woodall. Corresponding author: Prof. Dr. med. Ulrich Laaser DTM&H, MPH Section of International Public Health (S-IPH) Faculty of Health Sciences, University of Bielefeld E-mail: ulrich.laaser@uni-bielefeld.de Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 2 Abstract Aim: Agreeing on a Code of Ethical Conduct is an essential step in the formation and definition of a public health profession in its own right. In this paper we attempt to identify a limited number of key ethical principles to be reflected as professional guidance. Methods: We used a consensus building approach based on narrative review of pivotal literature and theoretical argumentation in search for corresponding terms and - in a second step - attempted to align them to a limited number of key values. The resulting draft code of ethical conduct was validated employing a framework of the Council of Europe and reviewed in two quasi Delphi rounds by members of a global think tank. Results: The alignment exercise demonstrated the acceptability of five preselected key principles: solidarity, equity, efficiency, respect for autonomy, and justice whereas three additional principles were identified during the discussion rounds: common good, stewardship, and keeping promises. Conclusions: In the context of emerging and re-emerging diseases as well as increase in lifestyle-related diseases, the proposed Code of Ethical Conduct may serve as a mirror which public health professionals will use to design and implement public health interventions. Future public health professional chambers or an analogous structure should become responsible for the acknowledgement and enforcement of the Code. Keywords: code of ethics, moral obligations, principle-based ethics, professional standards, public health profession, population ethics, societal responsibility, utilitarian ethics. Conflicts of interest: None. Acknowledgements: The authors express their gratitude to George Lueddeke who helped initiate the “One Health Global Think-Tank for Sustainable Health & Well-being (GHW 2030)” and chairs it since. Special thanks go to Think Tank members Muhammad Mahmood Afzal, Muhammad Wasif Alam, Mitike Getnet Kassie, and Joann Lindenmayer for their extensive review and comments which were of invaluable help. Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 3 Introduction The implementation of public health interventions raises ethical issues which require public health professionals to address them. The awareness of the ethical dimension of public health activities has given rise to the relevance of public health ethics, which Meagher and Lee refer to as “a subspecialty of bioethics” (1), and Kass refers to as a “subfield of bioethics” (2). Several authors have noted the importance of ethics for public health (3, 4), and public health professionals training (5). For example, ethical issues in public health also feature prominently in the efforts to control emerging infectious diseases at the population level (6, 7), which necessitated the World Health Organisation (WHO) to issue guidance on how to deal with ethical issues in infectious diseases control (8). Also, the efforts to address antimicrobial resistance (AMR) have raised a number of ethical questions (9). In a systematic review by Klingler et al., they have identified a comprehensive catalogue of ethically relevant conditions (10). Thus in order to address the ethical issues arising from public health practice and research, it has been noted that there is a need to establish a Public Health Ethics Framework and a Code of Conduct for public health professionals, as well as to train public health professionals in population ethics (11). Several Frameworks for Public Health Ethics have been documented (2, 12-15); among them, Marckmann et al. (12) have provided detailed reasoning on application in the field practice. However, a gap remains: the development of a Code of Ethics and Professional Conduct in the field of Public Health or in short: a Code of Ethical Conduct for the public health profession. In a recent introductory paper, Laaser and Schröder-Bäck (16) outlined the reasoning why a Code of Conduct is an essential step in the formation and definition of a public health profession in its own right at the national as well as the European level and with relevance to a global dimension. The European Directive on the recognition of professional qualifications 2005/36/EC (17) acknowledges as regulated professions in the health sector only physicians, nurses, dentists, midwifes, and pharmacists. The Amendment eight years later in Directive 2013/55/EU opens the door to include additional professions when it refers to a ‘broader context of the European workforce for health’ (18) which should then include for example veterinarians given their high relevance for people’s health. In most of the European countries, public health professionals are not formally organised as an autonomous profession in its own right – as for example it is the case in the United Kingdom (19) – and do not adhere to an agreed Code of Conduct (20). However, the “Good Public Health Practice framework published 2016 by the UK Faculty of Public Health 2016 (21) constitutes rather – as the title says – a guide for ethical practice which may be derived from overarching principles as discussed in this paper. Although there are organisations of schools of public health (22) and public health associations (23) as well as other associations related to areas of public health relevance, agreement on a Code of Conduct as one precondition for the formalisation and integration of a public health profession has not been promoted as necessary. The American Public Health Leadership Society (24) described the rationale for an ethical code of conduct in 2002 as: “…a code of ethics thus serves as a goal to guide public health institutions and practitioners and as a standard to which they can be held accountable”. The statement goes further beyond public health professionals to include institutions that are involved in public health to abide to ethical conduct. However, as a first attempt this did not initiate a lasting debate and the recent volume of the Public Health Reviews on Ethics in Public Health (25) touches the topic only indirectly. Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 4 In the introductory paper referred to above (16), Laaser and Schröder-Bäck discussed the limitations of the often dominant utilitarian principle in population ethics. The utilitarian principle says that the moral worth of an action or inaction lies in the consequences that follow. An action (or inaction) is good if it maximises the good for a maximum of people and is better in this regard than any alternative action. Intrinsic values – such as respecting persons or dignity – do not exist in utilitarian thinking. Instead of applying the utilitarian principle, the authors propose “...that solidarity and equity are core values that have to be reflected in a European version of a Code of Conduct for public health professionals… also guided by the principles of efficiency and respect for autonomy”. As an additional principle they discuss justice, especially for resource sharing on a global scale. Although these five principles reflect the European heritage, the authors underline the increasingly global dimension of the public’s health (26, 27, 28) and therefore of a public health profession well- defined by the same principles (29, 30). Methods We used a consensus building approach based on narrative review of literature and theoretical argumentation: we 1) argued the proposed five core ethical principles from the theoretical standpoint using a narrative review of selected publications in the field and trying to be as comprehensive as possible and relevant; 2) extracted and confirmed the five core principles as essential values for public health professionals and institutions in an “overlapping consensus” based on several rounds of discussion among authors, then translated the core principles into a draft Code of Ethical Conduct making use of ‘mapping the terrain’ as proposed by Childress et al. (31); 3) validated the draft employing the ‘General framework for codes of conduct in the health sector’ adopted by the Council of Europe in 2010 (32); and finally, 4) sent out the resulting draft for comments in two quasi Delphi rounds conducted by the Global Think Tank GHW-2030 (33). The comments from members of the Global Think Tank in round one have to a large degree been integrated by the authors. The second round revealed support in formulating the conclusions and recommendations and the approval of the second draft. Results Review of the literature with regard to corresponding terms Table 1 presents the selected and scrutinised papers related to principles and norms regarding Public Health Ethics. We carefully aligned and synthesised theoretical frameworks to find the best fit between them. The Draft Ethical Code The identified literature revealed its best fit with the five core values identified earlier (16): solidarity, equity, efficiency, respect for autonomy and justice. Three additional principles were identified in the alignment exercise, which are: common (public) good, stewardship, and keeping promises and commitments. In the following we explain their core normative meaning. Solidarity Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 5 Solidarity is a value that increases in significance in the health realm. Whereas in the conclusions of the Council of the European Union (38) solidarity was solely defined as being closely “linked to the financial arrangement of our national health systems and the need to ensure accessibility to all”, the normative scope, its relevance and meaning for public health gets more and more developed during the last years. A recent report of the Nuffield Council on Bioethics defines solidarity as a concept that “signifies shared practices reflecting a collective commitment to carry ‘costs’ (financial, social, emotional or otherwise) to assist others.” (41). Ter Meulen (42) emphasises that solidarity is more than respecting each other and assuming liberal negative rights of freedom but that positive relations among human beings should be in the forefront, next to rights and duties. He formulates: “Health care policies and arrangements should go beyond merely meeting needs and rights, by exploring how people’s personal dignity and sense of belonging can be sustained within relations of recognition, reciprocity and support”. From these essential cornerstones defining solidarity, one can conclude that the value of solidarity acknowledges that human beings should not forget that they are united, bond to other humans by virtue of humanity. From this also follows the duty for mutual support and the strengthening of relations among human beings should therefore be in the forefront of public health practice. Equity Also “equity” is one of the core values that are discussed in public health. The European Union defines equity in health simply as relating “to equal access according to need, regardless of ethnicity, gender, age, social status or ability to pay” (Council of the European Union 2006 (38)). However, equity is also the normative reminder that health inequalities have to be in the focus of all public health action if considered to be unjust and unfair (43), foremost all those which refer to religion, race, gender identity etc. Efficiency Despite the last values that focus on rights and stress the moral importance of every one, the value of “efficiency” stems from another philosophical school but the rights-based approach. “Efficiency” follows more utilitarian thinking inclined to maximize the positive outcome with a minimum of resources. This economic reasoning has a value - also from a moral perspective because it reminds public health professionals that one has to be careful when dealing with scarce resources. Scarce resources should be invested wisely to have the best health effect and economic evaluations are therefore important for public health. For instance, in some circumstances such as in the area of HIV/AIDS, there are challenging questions on how to allocate resources in an ethically acceptable and efficient way between preventive and curative demands (39) or between different health programmes. Also, in the example of antimicrobial resistance, the allocation of resources may require reprioritisation from other areas and sectors outside health in order to gather enough funding to support containment of the epidemic (9). Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 6 Table 1. Review of ethical principles and terminologies with relevance to public health Sources of Ethical Principles and Terminologies for Public Health Ethical Principles Proposed for Public Health Attempted Alignment of Ethical Principles for Public Health Professionals World Health Organisation [2016] (8) Justice Equity Transparency Inclusiveness/ Community engagement Accountability Oversight Utility Proportionality Efficiency Respect of persons (autonomy, informed consent, privacy confidentiality) Liberty Solidarity Reciprocity Solidarity Reciprocity Community engagement Equity Utility Efficiency Liberty Respect of persons (Autonomy, informed consent, privacy confidentiality) Proportionality Justice Transparency Inclusiveness/ Community engagement Accountability Oversight Core Ethical Principles Solidarity Equity Efficiency Respect for Autonomy Justice Littmann and Viens [2015] (9) Justice Distributive fairness Effectiveness Reciprocity Stewardship Citizen obligations to self- educate Citizens obligations not to infect others Citizen involvement in Responsibility Citizen obligations and actions Solidarity Public engagement Reciprocity Distributive fairness Effectiveness Responsibility Priority setting and resource allocation Risk information sharing Justice Distributive fairness Health justice Trust Public engagement Distribution of research outcomes Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 7 Sources of Ethical Principles and Terminologies for Public Health Ethical Principles Proposed for Public Health Attempted Alignment of Ethical Principles for Public Health Professionals lobbying Risk information sharing Distribution of research outcomes Public engagement Solidarity Reciprocity Health justice Common good Trust Royo-Bordonada and Roman-Maestre [2015] (11) Autonomy Solidarity Transparency Pluralism Community perspectives Rights of individuals Common good Partnerships (public-private partnerships) Collection and use of data (information) Solidarity Partnerships (public-private partnerships) Information (collection and use of data) Resource allocation Autonomy Rights of individuals Pluralism Community perspectives Core Ethical Principles Solidarity Equity Efficiency Respect for Autonomy Justice Marckmann G et al. [2015] (12) Maximizing health benefits Preventing harm Respecting autonomy Equity Efficiency Compensatory justice Transparency Participation Justification Equity Compensatory justice Maximizing health benefits Efficiency Respect for autonomy Justice Participation Justification Transparency Consistency Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 8 Sources of Ethical Principles and Terminologies for Public Health Ethical Principles Proposed for Public Health Attempted Alignment of Ethical Principles for Public Health Professionals Consistency Justification Participation Ortmann LE et al. [2016] (13) Utility Equity Justice Reciprocity Solidarity Privacy Confidentiality Keeping promises Effectiveness Proportionality Necessity Least infringement Public justification Solidarity Reciprocity Necessity Equity Effectiveness Utility Privacy Least infringement Confidentiality Proportionality Justice Public justification Public Health Leadership Society [2002] (24) Information Collaboration Respect for individual rights Diversity Incorporation Confidentiality Collaboration Information Respect for individual rights, Confidentiality Diversity Incorporation Information Core Ethical Principles Solidarity Equity Efficiency Respect for Autonomy Justice Schröder-Bäck P et al. [2014] (34) Maleficence Beneficence Health-maximisation Efficiency Respect for autonomy Justice Proportionality Justice Justice Efficiency Health- maximisation Respect for autonomy Proportionality Justice Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 9 Sources of Ethical Principles and Terminologies for Public Health Ethical Principles Proposed for Public Health Attempted Alignment of Ethical Principles for Public Health Professionals Laaser U et al. [2002] (35) Solidarity Equity Efficiency Sustainability Participation Subsidiarity Reconciliation Evidence Empathy/Altruism Solidarity Empathy/ Altruism Equity Subsidiarity Efficiency Sustainability Evidence Reconciliation Participation Sustainability Institute for Global Ethics [n.d.] (36) Competence Honesty Responsibility Respect Fairness Compassion Compassion Competence Responsibility Respect Honesty Fairness Council of the European Union [2006](38) Equity Universality Solidarity Solidarity Universality Equity World Health Organisation [2015] (39) Equity Solidarity Social justice Reciprocity Trust Individual liberty versus broader societal concerns Public good Distributive justice Solidarity Reciprocity Equity Allocating scarce resources Individual liberty versus broader societal concerns Distributive justice Social justice Trust Core Ethical Principles Solidarity Equity Efficiency Respect for Autonomy Justice Coughlin StS [2008] Minimizing possible harms Solidarity/social Effectiveness Least infringement Treating others fairly Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 10 Sources of Ethical Principles and Terminologies for Public Health Ethical Principles Proposed for Public Health Attempted Alignment of Ethical Principles for Public Health Professionals (40) treating others (current & future generations) fairly Sustainability Solidarity/social cohesion Precautionary principle Utility Public justification Least infringement Necessity Proportionality Efficiency Effectiveness Building and maintaining public trust Transparency (speaking honestly and truthfully) Keeping promises and commitments Protecting privacy and confidentiality Procedural justice (participation of the public and the participation of affected parties) cohesion Necessity Efficiency Sustainability Utility Protecting privacy and confidentiality Proportionality (minimising possible harms) Procedural justice (participation of the public and the participation of affected parties) Building and maintaining public trust Transparency Public justification Core Ethical Principles (summarised): * Additional ethical principles remaining after the attempted alignment (bold in the table) are: Solidarity (reciprocity) Equity Efficiency (utility, effectiveness) Respect for Autonomy (Respect for individual and community, Justice (public justification) Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 11 Sources of Ethical Principles and Terminologies for Public Health Ethical Principles Proposed for Public Health Attempted Alignment of Ethical Principles for Public Health Professionals • Common (public) good • Stewardship • Keeping promises and commitments privacy, confidentiality, least infringement) Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 12 Respect for autonomy Economic evaluation and utilitarian thinking have to be hold in check by the rights-reflecting values - equity, justice and also respect for autonomy. The normative core of the latter value is to re-iterate and focus what also is reflected in justice and equity: Every person has autonomy and thus the capacity to make own decisions (for children or other persons unable to consent, parents or guardians take this role). Respect for autonomy thus reminds public health professionals to obtain informed consent of persons who are subject to health interventions but also stresses that persons have a dignity that must not be comprised. This value warns of stigmatisation and instrumentalisation of persons for the benefit of others. If the autonomy of persons is comprised, this has at least the strong burden of proof that such an autonomy limiting behaviour is justifiable. However, respecting the autonomy of everyone not only means “to back off” and respect the liberty of a decision of persons. Rather, O’Neill (44) reminds the public health community that respecting autonomy can also refer to a duty, e.g. to participate in health interventions like immunisation campaigns to achieve herd immunity. Littman and Viens (9) in this context have noted that in order to address antimicrobial resistance “citizens have obligations to educate themselves, obligation of not to infect others, and obligation to lobby for support from political leaders and industries.” There might be examples where the infringement of a will of a person can be justified. The use of spillover effects of an intervention as a basis to restrict autonomy of an individual has been well explained by Royo-Bordonada and Roman-Maestre (11, pp. 12 of 15): “…among public health officials, there is a political component in the form of the health authority, with legal capacity in certain instances, to take action targeted at the individual or the environment. This capacity to restrict the autonomy of the individual can … come to be justified on the basis of the externalities, positive or negative, induced by the intervention in third parties”. An example could be to restrict the free movement of people with infectious diseases if their free movement could lead to severe infections of others. Justice When can we consider something as being unjust and unfair? A benchmark for justice theories in health is the work of Norman Daniels. Daniels (2008 (45)) follows his teacher Rawls in the assumption that public institutions are obliged to promote fair equality of opportunity for everyone. Public institutions and resources should be organized in such a way that every person can participate in society – to take public offices but also to have resources to live a good life (which is not further specified). Daniels continues the Rawlsian approach by claiming that health significantly contributes to the opportunity range that people are having. And, as a consequence, justice requires to protect health and to meet health needs of every person. Following the philosopher Boorse (46), Daniels also has a clear idea of what health means in this context: species typical normal functioning according to the functioning of others in the same (e.g., age) reference class. Thus, for public health professionals, justice understood in this way should remind them of including everyone to benefit from health and thus getting fair equality of opportunity in life when the social and other determinants of health (incl. access to health care) do not support this goal for everyone. The concept of distributive fairness includes also the important question of how findings from scientific research are distributed since research evidence is key for an informed Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 13 decision-making in public health. For instance, the tension in resource allocation between prevention and treatment in HIV and AIDS services can better be solved if decision makers know the evidence that treatment helps to minimize the risk of transmission, therefore, we can take treatment as part of prevention. In this way, the evidence for treatment as prevention can assist in distributive justice in resource allocation in HIV/AIDS between preventive and curative interventions. Also, by sharing research results, it will help communities to understand the value of interventions being implemented in public health and hence be more willing to support them. However, justice could also extend to include unproportionate focus on resource driven health programmes versus “other” public health calamities with significant impact. A key message to public health professionals is that distribution of research outcomes should be tailored to the audience, i.e., to the ordinary citizens; message should be prepared in simple, non-technical terms to ensure that it is clearly understood. The core principle of justice and its emphasis on transparency, inclusiveness, and community engagement provides an opportunity for people of different culture, values, and beliefs to participate in assembling public support. “Lessons from the Human Genome Project – Ethical, Legal, and Social Implications Program” (1) indicate that engaging the public in an informed discussion aiming at reaching agreement on a particular public health intervention, can help to get support of the population or community. Additional principles From table 1, three additional principles have emerged, namely: protection of common (public) good; stewardship; and keeping promises and commitments. Common (public) good This principle focuses on the need to protect things that are shared by all for the benefit of all people in the community, population or a nation. In economic theories the characteristics of a “public good” are those of being “non-excludable” and “non- rivalrous”. This means that all people can benefit from the good, no one is (or can be excluded), and use of the common good does not diminish the good. The “common (public) good” has close links to communitarian theories of public health ethics (47). This also requires public health professionals to be able to solve ethical conflicts between the protection of public good and human rights of individuals within a particular community or population (48). Knowing that priority is on preservation of common good should be the bottom-line for a Public Health Professional when implementing an intervention that encroaches on individual’s rights and freedom. If a Public Health Professional decides to focus on rights of individuals alone at the expense of a common good, this may put the whole community or population at risk. Also, the principle requires the Public Health Professional to be informed by scientific evidence while making decisions about a particular intervention. Stewardship This normative value insists that public health professionals have a stewardship role, which means that they have to put the health of the population as their number one priority (37). In other words, the stewardship role of public health professionals makes them responsible for the health of the entire population. As stewards, public health professionals must have a vision for the health of the people they serve. This brings to them a need for using scientific information to analyse situation and design Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 14 (jointly with the population) appropriate interventions. Also, public health professionals must build skills to engage the population and to reach consensus on public health interventions that will help to solve a problem at hand. If a Public Health Professional behaves as a “good steward”, then all stakeholders will likely support the implementation of public health interventions. To this end, public health professionals must be able to communicate effectively all the interventions as well as research findings to the population. Laws, regulations, and other tools for governance arrangements are part and parcel of the stewardship role. Therefore, Public Health Professionals in fulfilling their stewardship role should be able to participate in setting regulations and bylaws and support the populations to comply with in order to flourish healthy lives. Keeping promises This principle calls for public health professionals to hold themselves responsible on the promises and commitments they make. It should be understood by the professionals that commitment to improve and preserve the health of the population they serve is central to their duties. When a planned intervention is to be implemented in a particular community, it is the responsibility of the Public Health Professional to ensure that the promise is achieved in a transparent manner and that the resources earmarked for the intervention are used as planned. These three additional principles underline the relevance of operational ethical competence and are constitutive elements of public health professionalism. Validating the draft Code of Conduct For validation we found most suitable the general framework for codes of conduct in the health sector, approved by the Council of Europe in 2010 (32). In table 2 we attempt to show that the core ethical principles we identified can be aligned to a large degree with the framework adopted by the Council of Europe. Table 2. General framework for codes of conduct in the health sector of the Council of Europe (complete version in Annex 1) Main areas Subareas Selected examples Corresponding Core Principle 4. Areas to be regulated by a code of conduct in the health sector a. Good professional practice i. Respect for the dignity of people (employees…) ii. Honesty and confidentiality … iv. Use of the best scientific evidence … vi. Compliance with regulations and legislation vii. Awareness of the needs, demands and expectations of the population … 2.4 2.4 2.3 2.5 2.2 Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 15 b. Use of resources of the service/system i. Cost-effectiveness… ii. Avoiding using public resources for private gain iii. Prevention of fraud and corruption 2.3 2.5 2.5 c. Handling of conflict of interests… i. Economic: Weighing between health benefits and economic gains on one side and individual gains (employment, etc.) (45). ii. Non-economic: Managing relationships with health authorities and other government officials (11, 45). 2.6.1 d. Proper access, sharing and use of information … ii. Duty to disclose all relevant information… … 2.4; 2.5 e. Handling of gifts and benefits i. Existence of an explicit policy concerning gifts … 2.5 f. Research-related topics … ii. Truthful claims of research potential … iv.* Feedback to study populations on the results v.* Research outcomes as part of public good need to be shared in order to facilitate evidence-based decisions. 2.4 2.4 2.5 g. Relationships with other actors in the health sector … vii.* Collaboration between Public Health Professionals, Communities and Public Health Institutions. 2.1 2.6.1 h. Good corporate governance of health institutions/services/centres i. Issues of multiculturalism, tolerance and respect … ii.* Participation in humanitarian activities 2.4 2.1 2.6.2 5. Enforcement of the code of conduct a. Recognition of violations b. Composition of the body responsible for dealing with enforcement c. Transparency of procedures and public scrutiny d. Complaints system e.* Use of nudging techniques in design of public health interventions (46). This emphasis is based on the consideration that public Health Professionals need to balance application of nudging and strict prohibition. 2.5 2.5 2.5 2.5 2.3 2.6.2 2.5 6. Updating, a. Process of development of 2.6.1 Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 16 monitoring and development of the code of conduct codes of conducts: initiative, ownership, legitimacy b. Comprehensiveness c. Limitations of codes of conduct d. Codes of conduct and legislation 2.6.2 2.6.3 * Amended by E. Eliakimu. Results of two quasi Delphi rounds The final outcome of our integrating consensus oriented approach is summarised in table 3. Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 17 Table 3. The aligned code of ethical conduct for the public health profession Preamble: The public health profession is defined inter alia by an adopted set of principles guiding the ethical conduct of its members. These principles form a normative core of the profession. Public Health Professionals should orient their conduct – their doing and omission – according to the following norms and values. In case of conflict of these values, professionals accept a burden of proof to argue the ethically best acceptable solution for their conduct while taking the normative guidance of all these norms and values into account. Core ethical principles Short characterisation taken from section 2.1-2.5 above 2.1 Solidarity Solidarity signifies shared practices reflecting a collective commitment to carry ‘costs’ together to assist others. Human beings are united in the fact that they are bond to other humans by virtue of humanity. From this also follows the duty for mutual support for every human being. The strengthening of relations among human beings should therefore be in the forefront of public health. 2.2 Equity Equity is relating to equal access according to need, regardless of ethnicity, gender, age, social status or ability to pay. Health inequities considered to be unjust and unfair have to be in the focus of all public health actions. 2.3 Efficiency Maximisation of the positive outcome with a minimum of resources, i.e., scarce resources should be invested wisely to have the best health effect. 2.4 Respect for autonomy Economic evaluation and utilitarian thinking have to be hold in check by the rights-reflecting values - equity, justice and also respect for autonomy. Persons have a dignity that must not be comprised. 2.5 Justice Public institutions and public health professionals are obliged to promote fair equality of opportunity for everyone. This principle also encompasses distributive justice on research, i.e. to consider how findings from scientific research are distributed. Operational ethics Short characterisation taken from section 2.6.1 - 2.6.3 above 2.6.1 Common (public) good This principle focuses on the need to protect things that are shared by all for the benefit of all. Public health professionals must be able to solve ethical conflicts between the protection of public good and human rights of individuals. Knowing that priority is on preservation of common good should be the bottom-line for a Public Health Professional. 2.6.2 Stewardship Stewardship makes public health professionals responsible for the health of the entire population. They have to build skills to engage the population and to reach consensus on public health interventions that will help to solve a problem at hand. They should also support the citizens to comply with various laws and regulations governing public health issues. 2.6.3 Keeping promises This principle calls for public health professionals to hold themselves responsible for the promises and commitments they make. Promoting and preserving the health of the population they serve is central to their duties. Discussion The proposed Code of Ethical Conduct for the public health profession hopefully will become relevant in global and not just in European contexts. For example Anderson et al. (51) have highlighted a global health ethics in addressing the challenge of maternal and neonatal mortality. The identified principles make a significant contribution to the newer related field of “Global Health Ethics”, which has been shown to adopt almost similar values but operates at or requires actions at global level (52). Principles include equity, justice, Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 18 autonomy, human rights, application of scientific research, as well as related virtues such as compassion, trustworthiness, integrity, and conscientiousness. The World Health Organisation in its key document on Global Health Ethics has identified three ethical challenges that closely relate to these principles: first – “… to specify the actions that wealthier countries should take, as a matter of global justice and solidarity, to promote global health equity”; second – “… is related to cultural relativity. It is sometimes asked whether ethical standards are universal, given that different people in different countries may hold different values or place different weights on common values; third - concerns international research, especially when investigators from wealthy countries conduct research in impoverished settings where participants are especially vulnerable or where language and cultural barriers make informed consent difficult.”(39, pp. 19-20) The implementation of the Code of Ethical Conduct for the Public Health Profession, supports public health professionals addressing the ethical questions and dilemmas for the benefit of population health. Ethical principles including equity, social justice, national and individual autonomy, transparency, accountability, open communication, trust, mutual respect, development of servant leadership are characterised as globally relevant to meet the global challenges. Also, solidarity, stewardship, production of global public goods, and management of externalities across countries, have been shown to be the “essential functions of the global health system” (53). The role of human rights in health links both, public and global health ethics. To this end supporting, protecting and respecting human rights is essential both to Public Health Ethics (54) and to Global Health Ethics (55). However, e.g. out of fifty-five finalized project proposals identified in the Second Public Health Programme (2008-2013) of the European Commission only ‘equity’ and ‘efficiency’ were explicitly considered in eighteen projects and four projects respectively while solidarity was only discussed in one project (56). Limitations The limitations of our approach to public health or population ethics are obvious. Firstly, the selected literature may not be comprehensive respectively the balance between the relevance of publications and preferences of the authoring team may be biased by prejudice. Secondly our attempt to align relevant terms in the literature (see table 1) may similarly be biased by our prejudices, although our intensive discussions during the last year hopefully have minimised the effect of personal preferences. Thirdly, the terminology in the subject area has not finally matured leaving boundaries foggy and allow for undefined overlaps taking the example of public health vs. population health and global public health vs. global health where the latter terms include individual health predominantly subject of clinical medicine and the former terms are restricting to public health services and thereby to the multitude of public health professions working in the public health services (physicians, economists, sociologists to name a few). The authors of this paper however, do not consider public health ethics as a subspecialty (1) or a subfield (2) of bioethics. Although there are norms and values shared in bioethics and public health ethics, the latter has a basic normative orientation towards the good of the public and populations, whereas bioethics was designed for the clinical context of the patient-physician encounter (57). Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 19 Fourth, we embrace a public health ethics perspective but the purpose of this paper is to narrow it down to a Code of Ethical Conduct to guide multi-disciplinary public health professionals in their operations and to help defining a distinct profession targeting population health rather than individual health (16). This may imply the partly loss of a comprehensive picture, however, an elaborate guide or code would not serve the needs of the public health practitioner in the field. Insofar, we adopted a somewhat different strategy focussing on a smaller but comprehensive set of core principles (see table 3 above) relevant to public health ethics rather than prescribing a lengthy set of concrete rules (like e.g. 21, 24). Fifth, trying to be focused we did not elaborate on applications in the various fields of public health relevance as for example natural or man-made disasters and the resulting emergency state (58) which relates especially to the principle of solidarity, or the issue of universal health coverage (59) which requires the consideration of justice. Sixth, the focus on populations leaves out personal conscience and self-determination values (60) or virtues (61, 62), most important being honesty and trustworthiness, integrity and excellence. Finally, in light of the Sustainable Development Goals, SDGs (33) and the case for people and planetary sustainability becoming increasingly more urgent, it seems timely, although beyond the scope of this paper, to reflect on aligning the proposed ethical principles with the attainment of the SDGs, and for Public Health to adopt a wider perspective that underpins a One Health concept, that is, to encourage the collaborative efforts of multiple disciplines working locally, nationally, and globally, to achieve the best health (and well-being) for people, animals and our environment (63-66). Conclusions and recommendations The prospects of the Code of Ethical Conduct proposed here are related to its acknowledgement and enforcement which likely in the future can be done effectively only by own professional chambers or other suitable bodies for public health, not by common medical chambers as of now. 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Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 25 Annex 1. General framework for codes of conduct in the health sector of the Council of Europe (29) 1. Introduction 2. Values and ethical references 3. Legal framework of reference 4. Example of areas to be regulated by a code of conduct in the health sector NB. Not all areas are applicable to all situations. The order of the items does not reflect priority ranking. The list is non-exhaustive and the items are for illustrative purposes only. a. Good professional practice i. Respect for the dignity of people (employees, patients, customers) ii. Honesty and confidentiality iii. Keeping up-to-date professional competence iv. Use of the best scientific evidence v. Compliance with accepted standards vi. Compliance with regulations and legislation vii. Awareness of the needs, demands and expectations of the population, patients and customers viii. Co-operation with colleagues ix. Spirit of moderation, reconciliation, tolerance and appeasement b. Use of resources of the service/system i. Cost-effectiveness practice in the use of resources ii. Avoiding using public resources for private gain iii. Prevention of fraud and corruption c. Handling of conflict of interests in the best interest of patients and population, whether i. Economic, or ii. Non-economic d. Proper access, sharing and use of information i. Research of any information necessary for decision making ii. Duty to disclose all relevant information to the public and authorities iii. Duty to provide information to patients with respect to their needs and preferences e. Handling of gifts and benefits i. Existence of an explicit policy concerning gifts ii. Transparency regarding gifts received from interested parties f. Research-related topics i. Clinical trials (Helsinki Declaration) ii. Truthful claims of research potential iii. Patient consent with full disclosure of risks g. Relationships with other actors in the health sector i. Colleagues and other health professionals ii. Patients and their families iii. Insurers, third-party payers Laaser U, Schröder-Bäck P, Eliakimu E, Czabanowska K, The One Health Global Think-Tank for Sustainable Health & Well-being (GHW-2030). A code of ethical conduct for the public health profession (Original research). SEEJPH 2017, posted: 01 December 2017. DOI 10.4119/UNIBI/SEEJPH-2017-177 26 iv. Health-related industries (pharmaceutical, food, advertisement, cosmetic, medical devices, etc.), and other interest groups v. Government officers of health and other sectors (police) vi. Patients and self-help organisations, NGOs, etc. vii. Media h. Good corporate governance of health institutions/services/centres i. Issues of multiculturalism, tolerance and respect 5. Enforcement of the code of conduct a. Recognition of violations b. Composition of the body responsible for dealing with enforcement c. Transparency of procedures and public scrutiny d. Complaints system 6. Updating, monitoring and development of the code of conduct a. Process of development of codes of conducts: initiative, ownership, legitimacy b. Comprehensiveness c. Limitations of codes of conduct d. Codes of conduct and legislation ______________________________________________________________________________________ © 2017 Laaser et al; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The UK Faculty of Public Health. www.fph.org.uk/ (accessed: 19 February, 2016).