Agarici, S.; Elabassy, D.; Hirche, A.; Saha, R.; Witte, J.; Thomas, J.C. Proposing a European Public Health Code of Ethics. (Policy brief). SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 1 | 18 POLICY BRIEF Proposing a Code of Ethics for Public Health Professionals in Europe Sylvia Agarici1+, Darin Elabbasy1+, Anja Hirche1+, Royina Saha1+, Jente Witte1+, James C. Thomas* 1Faculty of Health, Medicine, and Life Sciences, Maastricht University, The Netherlands +These authors contributed equally to this work *Senior advisor Corresponding author: Sylvia Agarici, Email: sy.rici@yahoo.com Address: Universiteitssingel 60 6229 ER Maastricht, The Netherlands Agarici, S.; Elabassy, D.; Hirche, A.; Saha, R.; Witte, J.; Thomas, J.C. Proposing a European Public Health Code of Ethics. (Policy brief). SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 2 | 18 Abstract Context: Public health practitioners are involved in a wide array of contexts. Local and national government public health agencies; domestic and international nongovernmental organizations (NGOs); and academic institutions are just a few examples of the settings where public health practitioners work. Acting ethically and meeting ethical commitments in a practical and transdisciplinary endeavor as complicated as public health necessitates careful consideration. Ethical practice ensures that public health institutions work properly and that individual public health practitioners maintain their integrity. There is little debate about the importance of ethics in public health professional practice and, as a result, the necessity for a corresponding professional code of ethics. Policy Options: Only an US-American code of public health ethics has been created so far. Since ethical considerations in public health are heavily dependent in contexts, the aim of this document is to initiate a discussion surrounding the establishment of a Code of Ethics for Public Health Professionals in Europe. Recommendations:  Stimulate the discussion on a European code of public health ethics.  Make a clear distinction between public health ethics and medical ethics.  Recognize public health as a profession and not just a medical specialty.  Recognize the need for a common code of ethics among public health professionals in Europe.  Use Kotter's Model based on the Theory of Change as a roadmap when creating the European public health code of ethics.  Treat the European code of ethics as a "living document".  Encourage further research on a European code of ethics. Keywords: Code of public health ethics, European code of public health ethics, public health, public health values, public health ethics Acknowledgements: We thank Professor James C. Thomas for his guidance and support in developing this paper, as well as Professor Kasia Czabanowska for her help and for providing the opportunity to have explore this special project. We also thank all the interviewees for their time and contributions. Contributions: All authors contributed equally to this work. Conflict of interest: None declared Source of funding: None declared Agarici, S.; Elabassy, D.; Hirche, A.; Saha, R.; Witte, J.; Thomas, J.C. Proposing a European Public Health Code of Ethics. (Policy brief). SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 3 | 18 Introduction In early November 2021, the Austrian authorities announced that about two million people who had not been fully vaccinated against Covid-19 would be placed in lockdown. Shortly after, Germany introduced the same restrictions. Unvaccinated individuals were only allowed to leave their premises for limited reasons, such as working or grocery shopping (1). Meanwhile, protesters against Covid restrictions are dispersed using water cannons and tear gas in Belgium and Italy (2). These events demonstrate how reactions to protecting public health (PH) at the expense of individual moral rights and frustrated desires are not novel. They lead to the emergence of diverse ethical questions, such as the limits to individual freedom (3). This is where ethical codes are useful, as they are concerned with providing guidelines to answer such questions in formally written documents (4). Based on the idea that health professions are more than just special interest groups entrusted with serving the community, codes represent a societal pledge for the profession, which is part of a unique commitment and a second identity for the individual with values and norms relating to this society (4). Since different professions operate in different contexts with different societal expectations and values to attend to, each profession needs its code of ethics (5). For instance, biomedical codes of ethics might not be entirely applicable to PH (6). In Europe however, PH is yet to be recognized as a unique profession recognizing its multidisciplinary, instead of a medical specialty, as pointed out by PH experts during interviews for this policy brief (See Table 4, Appendix 2). There is no doubt about the relevance of ethics in PH professional practice and therefore, the need for a corresponding professional code of ethics. So far, only an American Code of PH ethics was developed (7,8). However, since PH is extensively based on social contexts, having a code of PH ethics for different regions would be more relevant to the unique ethical dilemmas related to PH interventions and the nature of societies historical backgrounds and values in each region. Currently, no European PH code of ethics exists, but there have been previous efforts to initiate the discussion around the creation of one (9,10). A plausible assumption is that the COVID- 19 crisis could lead to significant measures to mitigate the recent shortcomings witnessed in national responses within Europe (11). Part of this crisis and its aftermath might lead to better redistribution of resources, considerations being given to PH as its own profession, and most importantly, a recognized document or code which underpins the values, roles, and ethics of European PH decision-making. Hence, this policy brief calls for the establishment of a European PH code of ethics and suggests a framework that could possibly guide the development of a European code of ethics using Kotter’s model of change. Context Medical ethics and public health ethics First, for the purpose of developing a European PH code of ethics, it is important to make the distinction between medical ethics and PH ethics. According to Conti (12), medical ethics is focused primarily on individual health and cases, concerning itself with topics such as aspects relating to the desire for parenthood, changes of sex, or Agarici, S.; Elabassy, D.; Hirche, A.; Saha, R.; Witte, J.; Thomas, J.C. Proposing a European Public Health Code of Ethics. (Policy brief). SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 4 | 18 organ replacement. In essence, the values of autonomy, beneficence, non-maleficence, and justice are integral to the medical ethics approach (13). In contrast, PH ethics is concerned with a societal view of ethics (13,14). Issues regarding distributional differences, health inequalities across society, and other diverse topics, are of major concern and can be directly linked to the social determinants of health (13). The use of biometrics during HIV surveillance for example, highlights complex PH issues around privacy, the exposure of participants to risks of legal action or violence, the potential biassing of surveillance results, and the undermining of trust in the health care system, which are relevant for healthcare and PH professionals alike (15,16). This calls for action to clearly address the role of professionals in ethical dilemmas relating to PH and provide guidance for such matters. Public health ethics in the United States and Europe There remains the question of why a different code of ethics in Europe is needed, and the work of the American PH code of ethics should not merely be copied. In the United States, the PH code of ethics provides guidance on ethical analysis and action in policy and practice. It also highlights the importance of transparency, accountability, respect, and reciprocity. Furthermore, policy and practice guidance for twelve areas of ethical action is elaborated upon within the document, giving clear direction to PH ethics work (4). In contrast to the American PH code of ethics, the complexity of Europe requires special thought and consideration. Certain political realities, such as the French Revolution or Nazi Germany and the resulting Nuremberg Code, were responsible for the development of different value systems and thus to more solidarity-based health systems within Europe compared to the US (17). While current policy ideas headed by the EU such as commitments to minimize socioeconomic disparities and the promotion of a health-in- all-policies approach exist, PH remains a topic largely governed by the member states. Despite the different need for codes of ethics in Europe and the United States, European PH professionals should not completely step away from the American code of ethics. Camps et al. (17) have stressed that establishing PH ethics in Europe should incorporate the American code of ethics, as the fundamental key ideas do not differ significantly. However, innovations and even some adaptations regarding moral values in European societies should be made. Regardless of the universalities of moral obligations, the values that govern the PH decision-making of societies are different and therefore need to be regarded (17). Codes are based on values that relate to the contexts they will be applied to. Europe’s health values are based on a unique set of beliefs about health rights and duties which reflects the identity and the history of Europe. Therefore, the PH field in Europe is more likely to benefit from a code that is tailored based on European values than just adopting existing codes. Although it cannot be assured that all of Europe would fully adopt the document, it would allow European PH professionals to have a reference document which can guide and support PH decision-making. Values to be considered in European public health ethics As PH ethics evolves, a broader and more in-depth set of arguments regarding which Agarici, S.; Elabassy, D.; Hirche, A.; Saha, R.; Witte, J.; Thomas, J.C. Proposing a European Public Health Code of Ethics. (Policy brief). SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 5 | 18 values are at the core of PH practice in Europe will be seen. These values will be contrasted with the ones reflected in the American Public Health (PH) Code of Ethics while considering the differences between both societies (4). Justice and Equity Lundgren & Etheredge (18) advocate for justice, i.e., the notion for people to be treated equally. In PH ethics, the principles of justice advocate for people to be treated in a like manner and the health of the collective is prioritized. The American PH Code of Ethics states that all PH actions aimed at reducing health inequalities should be rooted in the values of justice and ethics (4). Here, equality implies that each person or group of people has the same access to resources and opportunities, while equity recognizes that circumstances for each person is different and gives the precise resources and opportunities required to achieve an equal result (19). Health justice encompasses not only the equitable allocation of scarce resources, but also the elimination of structural and institutional domination resulting from other disparities. The American PH Code of Ethics claims that it is difficult for PH to promote health justice at the transactional level unless it also works to promote it at structural and institutional levels (4). Similarly, European literature equally highlights the importance of equity as a health determinant, however, from the view of the European system, health equality refers to the commitment to diminish and eventually eradicate inequities in health and its determinants (20). The new code of ethics could further the value of equity from the groundwork laid by the American PH Code of Ethics into a health dimension that goes beyond individual factors and encompasses the socioeconomic, cultural, and environmental determinants of health (4). Autonomy: right to self-determination embedded within the social context The American PH code of ethics states that it is imperative for PH professionals to implement measures that respect the privacy and autonomy of all individuals and do the needful to minimize infringement upon personal liberties or adverse social and health outcomes (4). However, it is argued that European citizens tend to think of moral or social dilemmas on a more societal level due to the narrative surrounding the civic and cultural ‘European identity’ which is one of the underlying principles of the ‘European project’ (21). Nonetheless, Mah and Timmings (22) suggested that the role of PH ethics should be the notion that PH interventions, as mechanisms for operationalizing long-term health equity goals, should attempt to actively shift existing social norms. The existing deliberation between autonomy and broader population health continues to be one of great importance within PH ethics. Owens and Cribb (23) emphasize that freedom of choice does not equate to a policy that provides all people with the capability to be healthy. More attention should be drawn to the trade-offs between the right of self-governance and maximizing public health in a broadened discussion, addressing issues related to the intersection of individual-level factors and the social inequalities causing health disparities, including the question of added interference posed by this (23,24). According to Kavanagh et al. (15), justifications for activities that infringe on liberty and privacy must be based on considerations such as effectiveness of an intervention towards a legitimate PH goal, whether the benefits outweigh the harms, whether infringement is necessary to achieve Agarici, S.; Elabassy, D.; Hirche, A.; Saha, R.; Witte, J.; Thomas, J.C. Proposing a European Public Health Code of Ethics. (Policy brief). SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 6 | 18 the goal, whether the activity represents the least infringing option, and whether these actions have been publicly explained and communities consulted (15). A clear distinction between American and European ideological perspectives relating to autonomy can be recognized. According to Ellemers et al. (21), the pursuit of one’s health goals without state PH interference is central to an American perspective, whereas more Europeans agree that a certain extent of state interference is acceptable to guarantee that no citizen is in need. This could be owed to a higher degree of accountability that Europeans attribute to their governments, as well as the European ideology that the right to good health for everyone directly translates into better economic productivity (20). This could be a key area where the European code of ethics deviates from the American code of ethics by striking a more fitting balance between autonomy and interdependence, given the changing sociocultural dynamics post the COVID-19 pandemic. Solidarity and Interdependence Solidarity is the moral ideal that best describes the European concept of PH as a common good, mutual help, and shared responsibility for population health (25). It was pointed out during PH expert interviews (See Table 4, Appendix 2) that solidarity in the PH context should not only be recognized from a medical perspective, but rather in a holistic approach, accounting for the moral complexity in people’s relationships with one another, with non- humans and with the environment, and broadening the remit of PH ethics which may result in analyses that are more sensitive and useful (26). Focus should also be given to the inseparable association between solidarity and society. Solidarity should be practiced in a way that the scale or degree of institutionalization does not determine the moral worth or the ultimate importance of its enactment (26). Syrett (27) highlights that, while rearranging rights in a relational direction is not simple, it is not impossible. As such a development is based on conceptions of interconnection, it would considerably increase the potential of the right to health to be used in pursuit of community health goals and determinants of health (27). This would allow for a shift in moral focus from personal accountability to broader social issues and the pursuit of the common good. In the European context, solidarity permeates all dimensions of society: from healthcare, to economy, to politics. The structure and functioning of the European legislature discourage making hierarchical divisions that place one country higher than the others based on any parameter (28). Furthermore, interstate solidarity between European countries and interpersonal solidarity between European citizens are two key values which determine the dynamism and influence of Europe. Therefore, it is justified for a new European PH code of ethics to put more emphasis on solidarity and interdependence as essential determinants of good health. Legitimacy and Trust Dawson and Verweij (29) strongly advocate for three uses of legitimacy in the form of a normative concept, mandating an assessment of the legitimacy of actions. First, legitimacy should be seen related to the authority to make certain decisions and enact certain policies, second, legitimacy should be used as an angle to view fair Agarici, S.; Elabassy, D.; Hirche, A.; Saha, R.; Witte, J.; Thomas, J.C. Proposing a European Public Health Code of Ethics. (Policy brief). SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 7 | 18 processes and procedures in decision- making, and third it should be viewed differently than moral justification as it is concerned with what decides morally right or wrong. Schmidt (30) argues that the ability to gain normative legitimacy and trust is essential to the success of any PH intervention, highlighting the importance of this as a PH value. The American PH code of ethics recognizes that legitimacy and trust in public institutions can be enhanced by boosting public participation, but only touches upon it moderately. Europe thrives on strong social connections, shared customs, and a high level of public trust. Political legitimacy is regarded as a basic condition for good governance, and an authority not viewed as legitimate is regarded as ineffective in making decisions. The same notion, when stretched to the health of the public, clarifies why the legitimacy of health systems and PH professions are crucial within Europe. A new European code could use this as a starting point to advocate for further public participation with the objective to build legitimacy and trust in health systems (4). Policy Options To ensure the practical feasibility of creating a Code of Ethics for PH in Europe, a roadmap for creating this code is deemed necessary. Kotter’s 8-step model of change can be used as this roadmap to create change. Kotter's (31) eight-stage process for implementing major change has been acknowledged as one of the most well- known approaches to transformation, as the mainstream wisdom for leading change, and as the most compelling formula for success in change management (32–34). Creating a climate for change 1. Create urgency The first step that needs to be taken is creating a sense of urgency among PH organizations in Europe (35). There are several recent events that can stimulate this sense of urgency. An important example is the recent G26 meeting that took place in Glasgow, Scotland (36). The meeting concerning climate change confirmed the current high urgency for taking action and creating large- scale change. Climate change poses a large threat to the environment, biodiversity, and human-animal interaction, and consequently PH, adding to already existing PH ethical dilemmas This calls for immediate action to create a code of ethics for Europe, to have guidance and tactics to govern these dilemmas. Furthermore, the Covid-19 pandemic resulted in ethical questions, for example in relation to disease transmission and isolation mandates serving the purpose of protecting vulnerable groups within the population, posing an ethical dilemma of autonomy and freedom versus population health. According to Thomas and Miller (37), most ethical issues in PH arise from interactions between agencies, such as a local health department, and the population the agency is serving, like in the previous example (37). These are several reasons as to why specifically a guiding code of ethics can be an asset in PH. A European code of ethics can also be a basis for shaping guiding principles of national PH organizations, and additionally, it can serve as a basis for codes of ethics for a variety of disciplines within PH. Moreover, a European code of ethics can facilitate coordination and consistency among European countries. To have this consistency, the code must include decision- making processes and how they are communicated in the context of PH emergencies. This makes the code accessible and serves as a resource primarily for PH Agarici, S.; Elabassy, D.; Hirche, A.; Saha, R.; Witte, J.; Thomas, J.C. Proposing a European Public Health Code of Ethics. (Policy brief). SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 8 | 18 practitioners and all PH community members. Therefore, a sense of urgency is the first building block in creating change and initiating the discussion. This needs to be done among several stakeholders. Image 1. Stakeholder analysis Image 1 shows a rough stakeholder map to guide agencies and institutions that hold high-level individuals who can be at the front of leading the steps towards creating urgency. Collaboration must be actively sought out, sharing the common view of the urgency behind writing a European code of ethics. In the next section, the aspect of the collaboration will be elaborated on. 2. Form a powerful coalition Creating coalitions is an essential step in leading change; the key element of any successful process that creates change is collaboration (35,38). Especially in challenging times like these, it is important to stand together as PH professionals through common goals and shared values. Climate change, the COVID-19 pandemic, humanitarian disasters, increasing inequalities are only some examples of major challenges PH professionals are facing, and outlines the increasing importance and urgency of collaborating as a coalition on ethically dealing with forementioned crises. When creating a code of ethics for all European PH professionals, it should be a primary institution that takes the lead in collecting a group of stakeholders that come from a variety of institutions. This primary institution should be both high in interest and influence on the stakeholder map, such as ASPHER, EPHA or EUPHA, as it will be a key player in leading a collected group of stakeholders. This would be similar to how the first version of the American PH code of ethics was created, where fellows from the Public Health Leadership Institute, based in the US, took the lead in writing a first version of the American code of ethics (7). Another important stakeholder to include in this coalition would be national PH associations, organized in the World Federation of Public Health Associations (WFPHA), joining in taking the lead in writing a European code of ethics (39). In essence, it is PH professionals with some credibility that should be leading this process. A proposed list, in addition to the stakeholder map proposed above, can be found in the appendix. 3. Create a vision for change Public health leaders must craft a vision that is compelling for the future; a story that illustrates the power of a vision. This will be the vision that can be shared with the European PH community, and which provides the following according to Kaufman (40):  A clear sense of direction for the code of ethics and a foundation for what this code should be based on, Agarici, S.; Elabassy, D.; Hirche, A.; Saha, R.; Witte, J.; Thomas, J.C. Proposing a European Public Health Code of Ethics. (Policy brief). SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 9 | 18  A sense of engagement, purpose, and direction for European PH professionals, Empowerment, emotion, enthusiasm, and long-term motivation regarding the code of ethics among all European PH professionals,  Alignment between this vision and the strategy that will be the code of ethics,  A strong foundation for addressing competing priorities among PH professionals and ethical dilemmas (40). Visions are essential when creating change (35). The coalition mentioned in the previous step is the body responsible for creating a clear vision that meets the five requirements indicated above. Engaging and enabling the organization 4. Communicate the vision For communicating the vision that was established in the previous step, every opportunity possible to continuously communicate the change must be employed (35). A code of ethics that equips PH professionals with the tools needed to practice in an ethical manner still has to be written. The vision – a world where this code is already existing and employed – must be communicated clearly to the entire European PH community; be it PH professionals working in the field, large PH institutions or national bodies. Key elements that include effectively communicating the vision are explanation, repetition, use of multiple platforms and leading by example. The leading coalition is responsible for this effort, by walking the talk and setting the example (35). Specifying this to the code of ethics, communication about the code can take place in three different types of settings where the vision of an existing and employed code of ethics can be shared:  Through written word in the form of publications in academic journals, editorials, or influential online blogs.  In large settings such as conferences, events, or lectures.  On the personal level through strategic selection of influential PH professionals that can be invited to more informal settings to discuss a PH code of ethics. The code of ethics should not be written in stone, but rather be a living document, which will increase the likelihood of keeping the topic of a code of ethics on the agenda (39). Ultimately, this serves as an important step that ensures ethical practices which are worthy of public trust within PH (37). When communicating the vision, an effective way of doing this is through a compelling story (40). A story that celebrates the history of European PH ethics and that demonstrates the need for change, or, in other words, the need for a European code of ethics. Three drivers of needing change are essential points in a compelling story: crises, crises of confidence between the public and the PH professionals, and lastly, the story and code of ethics must respond to the 21st- century needs in the PH profession (40). 5. Empower action For this step, others must be empowered to act on the vision (35). For clarification purposes, the elements of the statement above should be adapted to the context of PH. In this case, “others” would include PH professionals and/or agencies who operate and influence decision-making in PH. The action is writing the code of ethics, and the vision would be the code of ethics being widely recognized but also practically applied. Agarici, S.; Elabassy, D.; Hirche, A.; Saha, R.; Witte, J.; Thomas, J.C. Proposing a European Public Health Code of Ethics. (Policy brief). SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 10 | 18 In order to empower action, one ought to get rid of any obstacles to change. An example of such an obstacle was mentioned by Schmidt (30), when discussing problems related to PH. Effective PH measures, must sometimes be implemented even though they might not, at least initially, be equally accepted by everyone. The potential reluctance may then cause problems to the general good, as populations may not comply voluntarily. A code of ethics would also struggle to reach unanimity, even after multiple drafts have been created. Understanding but also accepting the fact that such a document will face resistance, is the very first step that needs to be taken to tackle any future obstacles. Thus, the first and most crucial step in order to empower action is acknowledging that the European code of ethics for PH will be faced with controversy; just like any major PH policy seeking to create change. 6. Planning for and creating short-term wins Writing a code of ethics is a time-consuming process. The completion of such a task would be highly affected by a potential loss of momentum. To avoid this, the PH community and other stakeholders need to remain invested and willing to facilitate the process. Motivation may be lost if there is no tangible evidence of the success of the work conducted thus far. Hence, it is crucial to plan for visible improvements and recognize the importance of the work conducted by those involved. An example of a short-term win with long-lasting effects would be introducing PH ethics in public health education. While changing the entire curriculum of numerous professions is not a “short-term” process, there are ways to quickly integrate PH ethics through extracurricular activities. Such activities include, but are not limited to, conferences, seminars and even competitions organized with the scope of increasing awareness in the field of PH ethics. Implementing & sustaining for change 7. Build on the change This step entails consolidating achievements and generating additional change. "Do not declare triumph too soon," urges Kotter (31). It may take years for change to permeate profoundly into a culture. Henceforth, writing a European code of ethics for PH is not enough. The document has no credibility unless it becomes recognized and enforced by important PH stakeholders, such as the European Union. It is essential that the EU is to be involved in acknowledging first public health as an interdisciplinary public health profession, as well as a future code of public health ethics. Additionally, the code has the potential to be used as educational material for both existing and emerging PH professionals. 8. Anchor the change The final step regards instituting new approaches. When something becomes "the way we do things around here," it persists (31). There are two things that must be considered for the changes to become part of the culture. The first step is to demonstrate how the adjustments have improved performance. The second step is to guarantee that future PH professionals believe in and embrace the new practices. For example, in all communications addressed to PH professionals there should be a reminder of the ethical responsibility and values professionals need to attend to. Recommendations  Stimulate the discussion on a European code of public health ethics. Agarici, S.; Elabassy, D.; Hirche, A.; Saha, R.; Witte, J.; Thomas, J.C. Proposing a European Public Health Code of Ethics. (Policy brief). SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 11 | 18  Make a clear distinction between public health ethics and medical ethics.  Recognize public health as a profession and not just a medical specialty.  Recognize the need for a common code of ethics among public health professionals in Europe.  Use Kotter's Model based on the Theory of Change as a roadmap when creating the European public health code of ethics.  Treat the European code of ethics as a "living document".  Encourage further research on a European code of ethics. Conclusion Public health crises are becoming more frequent and with them come ethical dilemmas. This calls for ethical guidelines that can be used in all PH practices and a code of ethics that is specific to European values. A wide variety of professions have adopted codes of ethics that are specified to those professions and their context. However, PH is extensively based on social contexts, therefore, a worldwide generalization of one code of ethics, such as the adoption of the American code of ethics in Europe, would be inappropriate. European history and the wide variety of cultures requires attention to different historical aspects, as well as to different values. Moreover, cultural differences between European countries are essential to be considered as well to include all of Europe. Many current real-life problems that European PH professionals face daily urge a code to be developed as soon as possible. With a European code of ethics, PH professionals are empowered and equipped to make important decisions ethically. Furthermore, it could re-establish trust in PH decision-making among the public. To guide the development of a code, Kotter’s eight- step model to change is proposed as a guiding tool for creating a European code of ethics. This commentary suggests a starting point for developing a European PH code of ethics and calls upon influential PH organizations such as EUPHA, EPHA and ASPHER, to start the writing process for PH professionals to be equipped with fitting ethical strategies to stand ready for any current and future PH crises. Conflicts of interest The authors declare no conflict of interest. Funding This research received no grant from any funding institution in the public, private, or not-for-profit sectors. Acknowledgments First and foremost, the authors want to thank Professor James C. Thomas for his guidance and support in developing this paper. In addition, they would like to thank Professor Kasia Czabanowska for her help and for providing the authors with the opportunity to have taken on this special project. 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SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 15 | 18 Appendices Appendix 1: Organizations and contacts reached for the purposes of this project To carrying the vision of a European PH code of ethics forward, several contacts and organizations were identified, and are outlined in table 1. It must be advised that this is not an exhaustive list. Table 1: Organizations and Contacts who may provide guidance Name Title and Affiliated Organisation Interviewed? Dr habil. Peter Schröder - Bäck (P.) Professor for Ethics and Sociology at the Hochschule für Polizei und öffentliche Verwaltung NRW Yes, via Zoom Prof. John Middleton FFPH, FRCP President, Association of Schools of Public Health in the European Region (ASPHER) Yes, via Zoom Dr Farhang Tahzib Public Health Physician and Chair of the Ethics Committee, UK Faculty of Public Health Yes, via Zoom Assoc. Prof. dr hab. Katarzyna Czabanowska FFPH Maastricht University Public Health Leadership and Workforce Development, Leadership & Governance in European Public Health , Department of International Health, Care and Public Health Research Institute Yes, via Zoom - European Public Health Alliance (EPHA) - - Public Health University Wolverhampton (UK) - Agarici, S.; Elabassy, D.; Hirche, A.; Saha, R.; Witte, J.; Thomas, J.C. Proposing a European Public Health Code of Ethics. (Policy brief). SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 16 | 18 Appendix 2: Methodology Literature Review First, the literature review was used to examine the state of existing codes of PH ethics in Europe. Second, it allows the placement of the present document within the context of existing literature making a case for why further study is needed. Both objectives were fulfilled by reviewing existing literature and conducting short interviews, the details of which are presented below. Inclusion and Exclusion Criteria The information extracted from the literature was subjected to several inclusion and exclusion criteria. All the publications included in this paper were published from 2002 to 202. With regards to the topic of the literature screened, the search was limited to publications related to Public Health Ethics and/or existing Codes of Ethics in Public Health. Furthermore, to create a European framework, literature enlisting and describing European values was screened. For this parameter, literature relevant to bioethics was excluded. With respect to the types of literature considered, the research included several types of academic theoretical and empirical research (see table 2). On that aspect, non-peer reviewed publications and anonymous articles were disregarded. Finally, documents not written or available in the English language were not taken into account. Table 2: Search Inclusion & Exclusion criteria Parameter Inclusion Criteria Exclusion Criteria Topic Literature relevant to:  Public Health Ethics  Codes of Ethics  European values Literature relevant to:  Bioethics Type of literature Academic theoretical and empirical research including:  Journal articles  Research notes  Papers and abstracts from conference proceedings  PhD theses  Opinion pieces  Non-peer reviewed journals  Unpublished theses  Anonymous publications Agarici, S.; Elabassy, D.; Hirche, A.; Saha, R.; Witte, J.; Thomas, J.C. Proposing a European Public Health Code of Ethics. (Policy brief). SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 17 | 18  Governmental archives  Professional reports  Peer-reviewed articles Year of publication Published from 2002 to 2021 Published before 2002 Language Publications written or available in English Publications not written or available in English Search Strategy To thoroughly examine all of the available literature in a timely manner, a literature review was conducted. The two databases used for the literature extraction were PubMed and Embase. Table 3 below is a documentation of the search strategies used. Table 3: Search Strategy Database Research Strategy Results PubMed (((Public Health[Title]) AND ((Ethic*[Title]) OR ((Professional[title]) AND (Ethic*[title])) OR ((Decision Making[Title] AND (ethic*[title])) OR ((Decision Making[Title]) AND (ethic*[Title])) OR ((Professional[title]) AND (standard*[title]))) AND (code[Title]))) 9 Embase (‘PH’:ti AND ethics:ti OR ‘professional standard’:ti) AND [embase]/lim NOT ([embase]/lim AND [medline]/lim) AND [humans]/lim AND [english]/lim 66 Interviews Conducted Furthermore, four interviews were conducted to gain an understanding of the views of public health professionals who worked within ethics. Table 4 shows the names, dates, and methods by which the interview was conducted. Table 4: Interviews conducted Name Date of Interview Method Assoc. Prof. dr hab. Katarzyna Czabanowska FFPH 6th of October 2021 Via Zoom Dr habil. Peter Schröder - Bäck (P.) 12th of November 2021 Agarici, S.; Elabassy, D.; Hirche, A.; Saha, R.; Witte, J.; Thomas, J.C. Proposing a European Public Health Code of Ethics. (Policy brief). SEEJPH 2022, posted: 23 June 2022. DOI: 10.11576/seejph- 5606 P a g e 18 | 18 Prof. John Middleton FFPH, FRCP 24th of November 2021 Dr. Farhang Tahzib 7th of December 2021 ________________________________________________________________________ © 2022 Agarici 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.