Ethics in Community and Public Health – From …Subsidy for new full‐service grocery stores and supermarkets Your health unit has been asked to review the city’s Healthy Food

Ethics in Community and Public Health –From Simulation to Application

Workshop | Health Ethics Forum | March 2, 2016

Michael Keeling & Olivier BellefleurNational Collaborating Centre

for Healthy Public Policyfor Healthy Public Policy

The National Collaborating Centres for gPublic Health

2

National Collaborating Centre for gHealthy Public Policy (NCCHPP)

Our mandate– Support public health actors in their efforts to promote healthy

public policies

Our areas of expertiseOur areas of expertise– The effects of public policies on health– Generating and using knowledge about policiesGe e at g a d us g o edge about po c es– Intersectoral actors and mechanisms – Strategies to influence policy makingStrategies to influence policy making

3

Checking inChecking in…

What is your level of knowledge in /public/community health ethics?

Expert?

Intermediate?

Low?

4

What will we do today?What will we do today? I d h l d l f hi• Introduce the general nature and role of ethics frameworks in public health and community p yhealth

• Introduce summary versions of two such• Introduce summary versions of two such frameworks, and

A l h f k• Apply those frameworks to two cases.

5

What are our goals today?What are our goals today?

We want to: H l t k thi ibl f• Help to make ethics more accessible for you,

• Highlight tools that can help to systematicallyHighlight tools that can help to systematicallybring values into practice,

• Highlight the importance of deliberation for bringing those values into play with others andbringing those values into play with others, and

• Present a public health perspective as a complement to clinical and community ethics.

6

Outline / ScheduleOutline / Schedule1 00 1 30 I t d ti thi d i t ti1:00‐1:30 Introduction: ethics and orientation1:30‐2:00 Examining a case using an ethics frameworkg g2:00‐2:15 Analysis: what’s in an ethics framework?2 15 2 45 B k / di i2:15‐2:45 Break / discussion2:45‐4:00 Hands‐on practice: WRHA/MB‐PHEN frameworkp /4:00‐4:20 Same case with another lens4 20 4 30 W di i d l i4:20‐4:30 Wrap‐up, discussion and evaluation

7

L t’ t t ith blLet’s start with a problem

A recent news report has identified several areas in your city’s downtownseveral areas in your city s downtown core neighbourhoods as food deserts.

F d d id i i lFood deserts are said to exist in low‐income areas where residents do not have access (within 1 km) to ahave access (within 1 km) to a supermarket or a full‐service grocery store (min. 10 000 square feet).

As you may be aware, food deserts are often indicative of a host of interrelatedoften indicative of a host of interrelated economic, social and health inequalities, (inequalities in important determinants f h l h) ff d b l l idof health) suffered by local residents.

‘182’ Photo credit: Jan Kordylewski. www. Flickr.com Creative commons license: https://creativecommons.org/licenses/by/2.0/

Case inspired by: http://www.cbc.ca/news/canada/manitoba/buying‐groceries‐a‐long‐trek‐for‐family‐in‐winnipeg‐food‐desert‐1.3345126

And one responseCase 1:

And one response… Case 1:

Subsidy for new full‐service grocery stores and supermarkets

Your health unit has been asked to review the city’s Healthy Food for All program. One of the program’s key elements is anp One of the program s key elements is an incentive for any supermarket or full‐service grocery store that opens in an identified food desert in the next 3 years. These new stores would benefit from a 5‐year tax rebate co financed by the cityyear tax rebate, co‐financed by the city and the province.

‘Apple pile’ Photo credit: Doug Beckers. www. Flickr.com Creative commons license:

9

Creative commons license: https://creativecommons.org/licenses/by/2.0/

At first glance, are you in favour of subsidizing the opening of new full‐service grocery stores

and supermarkets in food deserts?and supermarkets in food deserts?

NoYes

Maybey

10

Why?There are many different ways of asking, h ld d thi ?W ld kshould we do this? We could ask:

1. Is this an effective way to improve health? (scientific and other evidence)

2. Is this cost‐effective? (economic analysis)

3 Who judges the status quo to be a problem and who is the most3. Who judges the status quo to be a problem and who is the most affected? (problematization, policy question, policy analysis)

h bli f hi ? ( bili )4. Is there public support for this program? (acceptability)

5. How will individuals and groups be affected by this? Are some groups more affected than others? Were they consulted? (ethical values more explicitly)

1‐5 all have ethical implications! (not just #5) 11

Wh t i bli h lth thi ?What is public health ethics?

Normative ethics

Bioethics

Cli i l Public Clinicalethics health

ethics

+ environmentalethics, animal ethics, etc.

Adapted from Dawson, 2010a12

Cli i l thi bli h lth thiClinical ethics vs public health ethics

Focus on populations

Focus on individuals Normative ethics

Patient seeksout clinician

PH practitionerseeks out ti t

PreventionCure

patientsBioethics

Clinical settings Communitysettings

Cli i l Public

Patient mayreject advice

Can be hard to opt out

Clinicalethics health

ethicsreject advice opt out

Should be in the May not be in the b t i t t f

+ environmentalethics, animal

Adapted from Dawson, 2010a

best interest of patient

best interest of some individuals

13

ethics, etc.

Where would you place community y p yhealth ethics?

Focus on populations

Focus on individuals Normative ethics

Patient seeksout clinician

PH practitionerseeks out ti tCommunity

PreventionCure

patientsBioethics

Community health ethics

Clinical settings Communitysettings

Cli i l Public

Patient mayreject advice

Can be hard to opt out

Clinicalethics health

ethicsreject advice opt out

Should be in the May not be in the b t i t t f

+ environmentalethics, animal

Adapted from Dawson, 2010a

best interest of patient

best interest of some individuals

14

ethics, etc.

Diff t ti i 1Different perspectives on an issue, 1

At what level should we look?Where they tend to focus:

This political economy?

Public HealthEthics?

MacroThis policy?

Meso This community? Community Health ethics?

Micro

This institution?

Micro

This person or patient?

This family or group? Clinical Ethics?

15

This person or patient?

Diff t ti i 2Different perspectives on an issue, 2P ti i t t b th illPerspectives are important, because they will:

Influence our problem framing:p gFor e.g.: Consider the interplay between

Micro – personal choice / autonomy / willpowerMacro built environment / choice architectureMacro Macro – built environment / choice architecture

Thus informing potential responses:

Meso

g p pInformation campaigns?Soda ban? (Etc.)

MicroAs well as situating responsibility for th blMicro the problem:

Collective?Institutional?

16

Institutional?Interpersonal?Individual?


Perspectives are important, because they will influence:

The focus ‐ what should I/we do:Advocacy for policy changes?

Macro Community empowerment?Reallocate resources?Provide counseling?

Meso

gProvide a referral to a program?…

Micro

Even when we work withindividuals at a small scale, it isMicrohelpful to keep the macro in viewas we think about multiple levels

17

of response.


But where do ourday‐to‐day

responsibilities tendMicroMicroMicroMicro

Micro responsibilities tend to lead our

MacroMicro

Micro

Micro

MicroMicro

MicroMicro

attention?MesoMicro Micro

Micro

MicroMicro

MicroMicro

Microi

Micro MicroMicroMicro

Micro Today we’ll take the time to lookMicro

MicroMicro

Micro

Micro

MicroMicroMicro

Mi

Today, we ll take the time to look at different perspectives…

18

MicroMicroMicro Micro

What is… …public health (PH) ethics?

PH ethics is mostly about what should and shouldn’t be done• collectively• to protect and promote the health of communities.

i h l h (CH) hi ?…community health (CH) ethics?CH ethics is mostly about what should and shouldn’t be doneCH ethics is mostly about what should and shouldn’t be done

• collectively• to protect and promote the health of communities• to protect and promote the health of communities• while “striving for the well‐being of individual clients”.

19(Last line, quoted material: Canadian Nurses Association, 2006)

Why public and community health y p yethics?

Because practisingethics can help us:

Because the choices we makecan have important

– See ethical issues

pconsequences for:

– Deliberate about options– Communities

– Groups

– Make decisions– Other individuals– Ourselves

– Justify them

20

What can we use to help us think about ethical issues in community/public health?

d fCodes of ethics ValuesNothing

Frameworks

Intuitions

Ethicaltheories

Principles

Frameworks

k

Principles Cases

Frameworks:• The most common approach• Help to highlight ethical values and issues• Help to highlight ethical values and issues• Help with deliberation and with decision making

21

Questions? Comments?Questions? Comments?

Next:

1:30‐2:00Examining a case using an ethics framework

Photo credit: the portable camera.Photo credit: the portable camera. All rights reserved.

22

R b bl ?Remember our problem?

A recent news report has identified several areas in your city’s downtownseveral areas in your city s downtown core neighbourhoods as food deserts.

F d d id i i lFood deserts are said to exist in low‐income areas where residents do not have access (within 1 km) to ahave access (within 1 km) to a supermarket or a full‐service grocery store (min. 10 000 square feet).

As you may be aware, food deserts are often indicative of a host of interrelatedoften indicative of a host of interrelated economic, social and health inequalities, (inequalities in important determinants f h l h) ff d b l l id

‘182’ Photo credit: Jan Kordylewski. www. Flickr.com Creative commons license: https://creativecommons.org/licenses/by/2.0/

Case inspired by: http://www.cbc.ca/news/canada/manitoba/buying‐groceries‐a‐long‐trek‐for‐family‐in‐winnipeg‐food‐desert‐1.3345126

of health) suffered by local residents.

And the response?Case 1:

And the response? Case 1:

Subsidy for new full‐service grocery stores and supermarkets

Your health unit has been asked to review the city’s Healthy Food for All program. One of the program’s key elements is anp One of the program s key elements is an incentive for any supermarket or full‐service grocery store that opens in an identified food desert in the next 3 years. These new stores would benefit from a 5‐year tax rebate co financed by the cityyear tax rebate, co‐financed by the city and the province.

‘Apple pile’ Photo credit: Doug Beckers. www. Flickr.com Creative commons license:

24

Creative commons license: https://creativecommons.org/licenses/by/2.0/

Let’s discuss this program with the help of p g pa public health ethics framework

Its goal: “for making transparent what the

t ti ll thi ll bl tipotentially ethically problematic aspects of a programme are and for evaluating to what extent a programme to prevent overweight or obesity is acceptable from an ethical point of view” (2012, p. 299).p ( , p )

Its structure: • 1st part: 8 questions to inform

the deliberation. ten Have et al. (2012). An ethical framework for the prevention of overweight and obesity: a tool for thinking through a programme’s ethical

• 2nd part: 8 steps for doing the deliberation.

tool for thinking through a programme s ethical aspects. European Journal of Public Health, 23(2), 299‐305.

25

deliberation.

ten Have et al (2012) 1ten Have et al. (2012)., 1

First part:

Q1. How does the program affect physical health?

• Is there evidence for its effectiveness?

• Is it cost‐effective?

• Are there unintended negative health effects?

26

What is the program aiming to do: p g gunpacking its logic1...

Will storesDo they have theWill stores

remain open after the end of the subsidy?

Between 50% and 75% of supermarketsoffer more unhealthy snacks than fruits and vegetables (Farley et al., 2009) and it

tends to be worse in low‐income

Are they really

affordable f h

have the time/

equipment?

Can they store perishables?

Focus of the program

tends to be worse in low incomeneighbourhoods (Cameron et al., 2013) for them? In‐store

marketing? Do they know how?

Identifyfood desert

Offersubsidy

New stores open

Healthyoptions are offered

Low‐incomepeople shop at the store

They buythe healthyoptions

They cookhealthierfoods

They eathealthierfoods

Their healthgets better

Chain of steps necessary for the program to be effective

Can theyWhat about Can they walk/take a bus to the

store (even in

Can they leave their children with a relative or do they have to

bring them?

?What about stores of less than 10,000

feet?

... and using ethics frameworks to help ask questions about the winter)? bring them?

27where the weak connections are, who is left out, etc...

1. To learn more about making logic models to show the assumed steps between an intervention and its ultimate health effects, see Morestin & Castonguay, (2013), Constructing a logic model for a healthy public policy: Why and how?


First part: As a partial example, a new supermarket in a food desert:


• In Philadelphia ‐ no change in fruit/vegetable intake or in


fruit/vegetable intake or in BMI (Cummins et al., 2014).

• In N.Y.C. ‐ no change in the intake of healthy foods (Elbel

• Is it cost‐effective?

intake of healthy foods (Elbelet al., 2015).

• In Pittsburgh ‐ reductions in • Are there unintended negative

health effects?

gintake of added sugars, but no effects re: whole grains, fruits and vegetables or BMIand vegetables or BMI (Dubowitz et al., 2015).

(as reported by Block & Subramanian [2015])

28


• New supermarkets can be associated with a perception of improved food

First part:p p p

access (Cummins et al., 2014).

• Neighbourhood stigmatization? Q2. How does the program affect

psychosocial well‐being? g g(Pushback from otherneighbourhoods?)• Are there unintended negative

psychosocial effects?• Effects on smaller stores? (Owners

and employees? Others?)

p y

• Stigmatization?

• What if some stores fail? Will local residents be blamed for not using it?

• What are the effects of local residents’ inclusion / exclusion fromthe process?

29


First part: • It targets low‐incomeneighbourhoods, but who’s reallygoing to shop there?

Q3. How does the program affect equality?

g g p– Price?– Transportation issues?– Housing issues?

h ?

• Are there groups in the population who are overrepresented in the at‐

– Know‐how issues?

• Will it offer culturally appropriateh lth ti th t fl t thp

risk category?

• How will the program affect

healthy options that reflect the neighbourhood’s profile?

Will it t ib t t t ifi ti• How will the program affect different groups?

• Will it contribute to a gentrificationprocess?

I i f i i i h i• Is it fair to existing stores, to theirowners/employees?

30


First part: • Seeking to change behaviour by enabling

Q4 How does the program affect

behaviour by enablingchoice. Non‐coercive.

Q4. How does the program affect informed choice?

• Many process‐related

Q5. How does the program affect social

Many process relatedunknowns: consultation, citizen participation/

and cultural values? engagement, communitydevelopment and neighbourhoodneighbourhooddevelopment.

31


d h ff

First part: • Is there a plan to evaluate healthy food intake? BMI?

Q6. How does the program affect privacy?

• Marketing: data collection?• Store evaluations: Customer

profiles?• Who’s gathering the information? • How? • Is confidentiality an issue?

profiles?

• Some public responsibility‐s co de a y a ssue

Q7. How does the program affect the attribution of responsibilities?

taking…• Does this represent a holistic

understanding of the multiattribution of responsibilities?

• Are responsibilities fairly balanced b t i di id l d

understanding of the multi‐layered challenges faced by community residents? You can

between individuals, groups and society?

build it, but will that suffice?

32


• The development processcould involve (or not)

First part:( )

local residents and organizations. Q8 How does the program affect

• There are various ways of developing communities

Q8. How does the program affect liberty?

D h i lib ?p g

and building on local assets versus imposing

• Does the program constrain liberty?

• Does it enable people or solutions from without.

• This starts long before a

communities?

gpolicy proposal.

33

What is the program aiming to do: Do theyhave the

p g gunpacking its logic1...Will stores

remain open after the end have the

time /equipment?

after the end of the subsidy? Between 50% and 75% of supermarkets

offer more unhealthy snacks than fruits and vegetables (Farley et al., 2009) and it


Are they really

affordable f h


Stigmatization?

Focus of the program

tends to be worse in low incomeneighbourhoods (Cameron et al., 2013) for them? In‐store

marketing?

Stigmatization?Do they

know how?

Identifyfood desert

Offersubsidy

New stores open

Healthyoptions are offered

Low‐incomepeople shop at the store

They buythe healthyoptions

They cookthem

They eatthem

Their healthgets better

Chain of steps necessary for the program to be effective

What about Effects on Can theyWhat about stores of less than 10,000

feet?

Effects on smaller existing stores?

Is the offer culturaly

appropriate?

Can they walk/take a bus to the

store (even in


bring them?

?

... and using ethics frameworks to help ask questions about

pp pthe winter)? bring them?

34where the weak connections are, who is left out, etc...

1. To learn more about making logic models to show the assumed steps between an intervention and its ultimate health effects, see Morestin & Castonguay, (2013), Constructing a logic model for a healthy public policy: Why and how?

S li d iDo they have the

Some policy domains:Will stores remain open after the end have the

time/equipment?




Are they really

affordable f h


Stigmatization? tends to be worse in low incomeneighbourhoods (Cameron et al., 2013) for them? In‐store

marketing?


know how?

Housing


feet?



appropriate?


store (even in


bring them?

?


35



time/equipment?




Are they really

affordable f h



marketing?


know how?

HousingFiscal/ employment


feet?



appropriate?


store (even in


bring them?

?


36



time/equipment?




Are they really

affordable f h



marketing?


know how?

HousingFiscal/ employment Education


feet?



appropriate?


store (even in


bring them?

?


37



time/equipment?




Are they really

affordable f h



marketing?


know how?


What about Effects on Can they

Transportation

What about stores of less than 10,000

feet?



appropriate?


store (even in


bring them?

?


38



time/equipment?




Are they really

affordable f h



marketing?


know how?



Transportation Marketing


feet?



appropriate?


store (even in


bring them?

?


39



time/equipment?




Are they really

affordable f h



marketing?


know how?


Child care


Transportation MarketingChild care


feet?



appropriate?


store (even in


bring them?

?


40



time/equipment?




Are they really

affordable f h



marketing?


know how?


Agriculture

Child care


Transportation MarketingChild care


feet?



appropriate?


store (even in


bring them?

?


h ?41

Do you see others?


1 D ib th ’ i k

Second part:

1. Describe the program’s main weaknesses. 2. Describe its main ethical strengths. 3. Discuss whether it is possible to adjust the program in order to maximize p j p g

its strengths and minimize its weaknesses.4. Discuss whether the program is likely to be effective in preventing

i ht d b itoverweight and obesity. 5. Discuss whether the program’s strengths outweigh its weaknesses. 6. Discuss whether there is an alternative program with fewer weaknesses. p g7. Discuss whether sound justification can be provided for the remaining

weaknesses. 8 D fi h th d d h t diti th i t bl8. Define whether and under what conditions the program is acceptable

from an ethical point of view.

42

Are you in favour of subsidizing the opening ofAre you in favour of subsidizing the opening of new full‐service grocery stores and supermarkets in food deserts?

NoYes NoYes

MaybeMaybe

43


Next:

2:00‐2:152:00 2:15Analysis: what’s in an ethics framework?ethics framework?

Photo credit: the portable camera. All rights reservedAll rights reserved.

44

What is a framework? What can it offer?

No need to be a specialist to use one Designed to guide

i

Can help to reduce (not eliminate) some of the effects of cognitive andpractice effects of cognitive and

other biases

FlexibleProvides an entry point and a structure for

d lib tideliberation

A formula, an algorithm or a

‘Frames’A lens for looking at, and thereby seeing,

algorithm or a flowchart

y g,ethical issues

Requires a criticalperspective

Inspired by: Dawson, 2010b, pp. 192, 200. 45

perspective

H d th diff ? (1)How do they differ? (1)

“Framing” the issues:

P i lib l P i i iPerspective more liberal(emphasis on individual autonomy)

Perspective more communitarian(emphasis on common goods)

Childress et al., 2002

Upshur, 2002Baylis et al., 2008

Tannahill 2008

Kass, 2001

Thompson et al., 2006

WRHA, 2015Tannahill, 2008

Public Health Leadership Society, 2002 ten Have et al., 2012

46See MacDonald, 2015: http://www.ncchpp.ca/127/Publications.ccnpps?id_article=1426


Scale/perspective:

More meso‐macro: ten Have et al.

Macro Some focus more atpolicy/program/structural/ population/macro levels

Meso More micro: WRHA’s framework

population/macro levels…

Micro

Some focus more on what to do in an individual /situation level…

Micro

However, the borders betweenare permeable

47

are permeable.


Scope:For any situation:

K 2001Kass, 2001Marckmann et al., 2015WRHA, 2015

To justify public health interventions that infringe uponthat infringe upon individual autonomy:

U h 2002Upshur, 2002For specific issues or situations:

Ob it t H t l 2012Obesity: ten Have et al., 2012Pandemic: Thompson et al., 2006


Form:

• Principle‐based frameworks:Propose a series of principles to consider– Propose a series of principles to consider

• Childress et al., 2002• Upshur 2002

‐Harm principle‐Least restrictive means• Upshur, 2002

i b d f k

‐Reciprocity‐Transparency

• Question‐based frameworks: – Pose a series of questions that evoke principles or values

• ten Have et al., 2012• WRHA, 2015• Public Health Ontario, 2012 49

How do they differ? (5)o do t ey d e ? (5)

Method: explicit or assumed?

Rationale: why these principles for this issue?y p p

Justification: what is the source of the ethical ‘should’?Justification: what is the source of the ethical should ?

Procedure: practical guidance and some order or structure to help users to apply the principles and b l h i f flibalance them in cases of conflict.

50


Next:

2:15‐2:45B k / di iBreak / discussion

2:45 4:002:45‐4:00Hands‐on practice: WRHA/MB‐PHEN frameworkPHEN framework

Photo credit: the portable camera. All rights reserved.

51

Let’s consider another caseMarla is a 20 year old living with her boyfriend, Dan, 35 years, and new baby Arielle in an apartment

downtown. Marla did not access prenatal care, and her first contact with the health care system was when she delivered her baby.

Marla and Dan both receive Employment and Income Assistance Marla says her family is from a FirstMarla and Dan both receive Employment and Income Assistance. Marla says her family is from a First Nation community outside of town and she does not see them often. Her family has no plans to visit, as money is too tight. She says she no longer spends time with most of her friends since baby’s birth. Although Marla says that she does not drink alcohol, she says that Dan’s alcohol use is frequent Marla says most of his time he spends with his friends in the block who also like to drinkfrequent. Marla says most of his time he spends with his friends in the block who also like to drink alcohol.

Marla screened as high risk for abuse/neglect parenting, and the Public Health Nurse (PHN) wanted to recommend the Families First program to her. However, due to staff vacancies, there were no Families First home visitors available. The PHN linked Marla to local resources, and then continued to connect with Marla by phone to help with expressed needs. When Arielle turned 3 months, a space became available in Families First, Marla reluctantly agreed to participate, and the PHN enrolled her in the program.p g

Andrea, the Families First Home Visitor assigned to Marla, Dan and Arielle, began making home visits and working with Marla. Dan was often out visiting with his friends during home visitor visits, and chose not to engage in activities with Arielle when he was around.

Arielle was 5 months old when Andrea arrived at the apartment one day Dan was assumed to beArielle was 5 months old when Andrea arrived at the apartment one day, Dan was assumed to be asleep in the bedroom after a visit with his friends, and Marla was visibly upset. Marla confessed that she had discovered bedbugs in the home, but expressed concern Dan would not allow her to call anyone about them as he distrusts visitors. As they talked, Dan barged out of the bedroom,

t d d With t ki h t th t lki b t D b lli i lt taggravated and angry. Without asking what they were talking about, Dan began yelling insults at Marla, and ordered Andrea to leave. Feeling threatened and aware of safety risks, Andrea left, and called her Case Manager from the car.

hi d l d d id d b h k hi i k l bli52

This case was developed and provided by WRHA. Thank you to Cathie Pickerl, a WRHA public health nurse, for providing valuable input in the writing of this case study.

The scenario and names are fictitious. You will find a paper copy on the table.

We will analyze the case using WRHA’s(2015) ethical framework

• On each table, you will find:– The case/story of Andrea and Marla, along with a 2‐page summary of the questions from the WRHA p g y qframework (there is a copy for everyone)Summary of questions with space for responses– Summary of questions with space for responses (one copy, for a recorder/reporter)

Winnipeg Regional Health Authority, Ethics Services. (2015). Ethical Decision‐Making k id I f d i l i d fFramework: Evidence Informed Practice Tool. Retrieved from:

http://www.wrha.mb.ca/extranet/eipt/EIPT‐037.phpFramework (PDF): http://www.wrha.mb.ca/extranet/eipt/files/EIPT‐037‐001.pdf

53

Workbook (PDF): http://www.wrha.mb.ca/extranet/eipt/files/EIPT‐037‐002.pdf

The WRHA Framework…

Four main steps:

I. Clarifying the ProblemII. Describing the Ethical ConsiderationsIII Choosing a SolutionIII. Choosing a SolutionIV. Implementing and Evaluating

A t t l f 17 ti d b tiA total of 17 questions and many sub‐questions

54

We propose 2 blocks of deliberationp pFirst – Clarifying the

problem(s)Then – What to do about

the problem(s)?problem(s)• 20 minutes (your table) to

the problem(s)?• 20 minutes (your table) to

discuss the case:– People

deliberate:– Weigh principles

– Issues– Values

– List options– Consider perspectives

– Stakeholders

• Using the questions– Decide

• Using the questionsUsing the questions highlighted 10 i t t di

Using the questions highlighted10 i t t di• 10 minutes to discuss

main points (all together)• 10 minutes to discuss

main points (all together)

55This will take us through much of the framework, in order.

1st block: clarifying the problem(s)…y g p ( )Focus on: What is the main problem? (Or problems?) Revisit the facts: what you know, what you need to e s t t e acts at you o , at you eed to

find out What are the most important issues? What are the most important issues? What values are involved? List major stakeholders/ (Incl.: Who is affected?

Who decides? Are perspectives different? Who ismissing from the discussion?)

Please take some notes to capture and share your group’s main ideas

56

Please take some notes to capture and share your group s main ideas

2nd block: what to do about the problem(s)problem(s)…

Focus on: List the ethical principles involved/ What conflicts exist

between/among them? List options (choose 2‐3 possible options) Make a choice and justify it (using your prior Make a choice and justify it (using your prior

considerations of issues, principles, conflicts, trade‐offs, etc )etc.)

Is there anymoral distress or residue from the situation that needs to be considered or acted upon?

Are there implications for policy?p p y

Please take some notes to capture and share your group’s main ideas

57

p y g p


Next:Next:

4:00‐4:20Same case with anotherSame case with anotherlens

Photo credit: the portable camera.Photo credit: the portable camera. All rights reserved.

58

The same case with a different lens(4:00 4:20)(4:00‐4:20)

• Now that we have become more familiar with Marla’s• Now that we have become more familiar with Marla s situation and have proposed some actions,

• Let’s apply the framework by ten Have et al. (2012) to the case to see what kind of perspective athe case to see what kind of perspective a program/policy‐level focus gives.

(hint: we might not see much of Marla in this exercise….nor Andrea, Arielle or Dan…)

• Note: this framework was developed for programs to combat obesity – we think that it is more generally applicable but that is open to debate.

59


First part: From Families First Program Evaluation Report. Goal ‐ to see program outcomes “under real‐world service delivery conditions” (p 4)


world service delivery conditions (p. 4).

Positive effects:


–improved child health–increased preschool education–Decrease in child abuse

• Is it cost‐effective? No effects:maternal health

• Are there unintended negative health effects?

–maternal health–family functioning–family economic functioning –exposure to adverse life events

60Families First Program Evaluation Reporthttp://www.gov.mb.ca/healthychild/familiesfirst/ff_eval2010.pdf

ten Have et al (2012) 2ten Have et al. (2012)., 2• Increased positive parenting• Evaluation report shows some

i i ’

First part:improvements in parents’ well‐being; in other areas none

Q2. How does the program affect psychosocial well‐being?

• Gap: mental health resources/referrals/training

• Has program created or• Are there unintended negative

psychosocial effects? • Has program created or increased tension between Marla and Dan?

p y

• Stigmatization?

• Stigma: how is program received by families and how is ‘at‐risk’ framedis at risk framed

• Distress for home visitors?

61


First part: • Universal screening (95% rate among families with a postpartum referral)

Q3. How does the program affect equality?

postpartum referral)• First Nations families living on

reserves are not screened

• Are there groups in the population who are overrepresented in the at‐

• 83% (est.) of all births in Manitoba are screened

• 25% who screen as ‘at risk’prisk category?

• How will the program affect

• 25% who screen as at risk never engage in the program; 16 month average duration of

ti i ti i• How will the program affect different groups?

participation in program• Cultural competence/

sensitivity extremelysensitivity extremely important

62


First part: • ‘Guiding’ to informed choices• This will depend on visitors’

l ti hi ith f ili (th i

Q4 How does the program affect

relationships with families (theirskills, time, training, support and resources, and program parameters).

Q4. How does the program affect informed choice?

• Depends on resource networks (social workers, other sectors)

• Also depends on adapting services to

Q5. How does the program affect social

families’ abilities and circumstances, and their socioeconomic and cultural situations.

and cultural values? • The program aims to work with

people’s strengths and to be lt ll iti Thi hculturally sensitive. This may have

improved Indigenous families’ participation rates.

63


First part: • Screening form:– 39 biological, social and

demographic factorsQ6. How does the program affect

privacy?

demographic factors– When 3 or more risk factors are

identified: Parent Survey to assess parenting supports and challenges

• Who’s gathering the information? • How?

I fid ti lit i ?

• Follow‐up?• Evaluation?

• Is confidentiality an issue?

Q7. How does the program affect the

• Society has taken a role in valuingoutcomes for newborns throughsupport for at‐risk families

attribution of responsibilities?

• Are responsibilities fairly balanced

• Too much (and too multifactorial) burden placed upon visitors?

• How can visits help marginalized p ybetween individuals, groups and society?

families? (multigenerational, systematic, deeply embedded)

• Are families responsible for too h? T littl ?

64

much? Too little?


• Family refusal is possible• Marla reluctantly agreed

First part:y g

to participate.(i.e., she is not wholly

f t bl ithQ8 How does the program affect comfortable with participation, and clearly Dan is not )

Q8. How does the program affect liberty?

D h i lib ? Dan is not.)• What are real or

perceived implications of

• Does the program constrain liberty?

• Does it enable people or perceived implications of participation? At risk of further intervention by

h i i ?

communities?

authorities?

65


1 D ib th ’ i k

Second part:

1. Describe the program’s main weaknesses. 2. Describe its main ethical strengths. 3. Discuss whether it is possible to adjust the program in order to maximize p j p g

its strenghts and minimize its weaknesses.4. Discuss whether the program is likely to be effective in preventing

i ht d b itoverweight and obesity. 5. Discuss whether the program’s strengths outweigh its weaknesses. 6. Discuss whether there is an alternative program with fewer weaknesses. p g7. Discuss whether sound justification can be provided for the remaining

weaknesses. 8 D fi h th d d h t diti th i t bl8. Define whether and under what conditions the program is acceptable

from an ethical point of view.

66

DiscussionQuestions, and Evaluation forms

• All of this material will be made available on o r ebsite later in March (in French andour website later in March (in French and English).

• Please complete your evaluation forms before you go – we really use thoseyou go we really use those….

Thank you!

67

Resources

68

Here are a few principles that are commonly used in public health ethics frameworks:

S b t ti P d lSubstantive

• Duty to provide care • Proportionality

Procedural

• Accountability• Effectiveness• Equity / social justice

H i i l

• Protection of the public

• Reciprocity

• Inclusiveness• Participation

R bl• Harm principle• Least restrictive

means

• Reciprocity• Respect• Solidarity

• Reasonableness• Responsibleness• Responsiveness

• Necessity• Precautionary

principle

y• Sustainablity• Stewardship

Responsiveness• Transparency

principle

Substantive: these can help to reveal ethical issues and to to make and justify decisions in specific contexts. Procedural: these can help in making ethical choices concerning the processes by which programs, policies etc. are realized.

For further information: Please send us an email and we can refer you to several interesting resources Or you can findFor further information: Please send us an email and we can refer you to several interesting resources. Or, you can findthese by consulting the frameworks that are listed on the next few slides.

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Links to selected frameworks for public health ethicsp(these are also a good source for learning about normative principles)

B N M G ll t S E G ld S D & J b P D (2007) L ki h d Add i thi l h llBaum, N. M., Gollust, S. E., Goold, S. D., & Jacobson, P. D. (2007). Looking ahead: Addressing ethical challenges in public health practice. Global Health Law, Ethics and Policy, Winter 2007, 657‐667. Available at: http://deepblue.lib.umich.edu/bitstream/handle/2027.42/75478/j.1748‐720X.2007.00188.x.pdf?sequence=1&isAllowed=yp q yOur adapted summary is available at: http://www.ncchpp.ca/docs/2016_eth_frame_baum_En.pdf

Baylis, F., Kenny, N. P., & Sherwin, S. (2008). A relational account of public health ethics. Public Health Ethics, 2008, 1‐14. Available at: http://noveltechethics.ca/files/pdf/259.pdf

Bernheim, R. Gaare, Nieburg, P., & Bonnie, R. J. (2007). Ethics and the practice of public health. In R. A. ( )Goodman, R. E. Hoffman, W. Lopez, G. W. Matthews, M. Rothstein, & K. Foster (Eds.), Law in public health

practice, pp. 110‐135. Oxford: Oxford University Press. For information (paywall): http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780195301489.001.0001/acprof‐97801953014899780 9530 489Our adapted summary is available at: http://www.ncchpp.ca/docs/2016_eth_frame_bernheim_En.pdf

Canadian Nurses Association. (2006). Public health nursing practice and ethical challenges. Ethics in Practice for Registered Nurses, February 2006, 12 pp. Ottawa: Canadian Nurses Association. Available at: http://cna‐aiic.ca/~/media/cna/page‐content/pdf‐en/ethics_in_practice_jan_06_e.pdf

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Selected frameworks (2)Selected frameworks (2)Carter, S. M., Rychetnik, L., Lloyd, B., Kerridge, I. H., Baur, L., Bauman, A., Hooker, C., & Zask, A. (2011).

Evidence, ethics and values: A framework for health promotion. American Journal of Public Health, 101(3), 465‐472. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3036693/pdf/465.pdf

Childress, J. F., Faden, R. R., Gaare, R. D., Gostin, L. O., Kahn, J., Bonnie, R. J., Kass, N. E., Mastroianni, A. C., Moreno, J. D., & Nieburg, P. (2002). Public Health Ethics: Mapping the Terrain. Journal of Law, Medicine & Ethics, 30 (2), 169–177. Available at: http://www.virginia.edu/ipe/docs/Childress_article.pdf

Child J F & B h i R G (2015) I t d ti A f k f bli h lth thi I R G B h iChildress, J. F. & Bernheim, R. G. (2015). Introduction: A framework for public health ethics. In R. G. Bernheim, J. F. Childress, R. J. Bonnie and A. L. Melnick (Eds.), Essentials of Public Health Ethics. Burlington, MA: Jones and Bartlett Learning. Available at: http://samples.jbpub.com/9780763780463/Chapter1.pdf (N.b.: 20 MB).)

Désy, M., Filiatrault, F., & Laporte, I. (2012). A tool for ethical analysis of public health surveillance plans. In Canadian Institutes of Health Research – Institute of Population and Public Health, Population and Public H l h E hi C f R h P li d P i ( 52 57) T O U i i f THealth Ethics: Cases from Research, Policy, and Practice (pp. 52‐57). Toronto, Ottawa: University of Toronto Joint Centre for Bioethics. Available at: http://www.jcb.utoronto.ca/publications/documents/Population‐and‐Public‐Health‐Ethics‐Casebook‐ENGLISH.pdf

Fry, C. (2007). Making values and ethics explicit: a new code of ethics for the Australian alcohol and other drugs field. Canberra: Alcohol and other Drugs Council of Australia. Available at: http://www.adca.org.au/wp‐content/uploads/ethics_code.pdf

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Selected frameworks (3)Selected frameworks (3)Gostin, L., Mann, J. M., & Gostin, L. (1994). Towards the development of a human rights impact assessment

for the formulation and evaluation of public health policies Health and Human Rights 1(1) 58‐80for the formulation and evaluation of public health policies. Health and Human Rights, 1(1), 58 80. Available at: http://academic.udayton.edu/richardghere/NGO%20Man/Gostin%20article.pdf

Gostin, L. (2003). Public health ethics: Tradition, profession and values. Acta Bioethica, 2003; año IX, No 2, , ( ) , p , ; , ,177‐188. Available at: http://www.scielo.cl/pdf/abioeth/v9n2/art04.pdf.

Grill, K. & Dawson, A. (2015). Ethical frameworks in public health decision‐making: Defending a value‐based and pluralist approach. Health Care Analysis, 2015, July 14. Available at: http://link.springer.com/article/10.1007/s10728‐015‐0299‐6/fulltext.html

Kass, N. E. (2001). An ethics framework for public health. American Journal of Public Health, 91(11), 1776–1782. Available at: http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.91.11.1776Our adapted summary is available at: http://www.ncchpp.ca/docs/2016_eth_frame_kass_En.pdf

Marckmann, G., Schmidt, H., Sofaer, N., & Strech, D. (2015). Putting public health ethics into practice: A systematic framework. Frontiers in Public Health, February 2015, 3(23), 8 pp. Available at: http://journal.frontiersin.org/article/10.3389/fpubh.2015.00023/fullOur adapted summary is available at: http://www.ncchpp.ca/docs/2015_TOPHC_Ethique_HandoutB_EN_Final.pdf

N Z l d E hi Ad i C i (2007) G i h h h E hi l l f d iNew Zealand Ethics Advisory Committee. (2007). Getting through together: Ethical values for a pandemic. Wellington: Ministry of Health. Available at: http://neac.health.govt.nz/system/files/documents/publications/getting‐through‐together‐jul07.pdf 72

Selected frameworks (4)Selected frameworks (4)Public Health Leadership Society. (2002). Principles of the ethical practice of public health. Available at:

http://www phls org/home/section/3‐26/http://www.phls.org/home/section/3 26/

Schröder‐Bäck, P., Duncan, P., Sherlaw, W., Brall, C., & Czabanowska, K. (2014). Teaching seven principles for public health ethics: Towards a curriculum for a short course on ethics in public health programmes. p p p gBMC Medical Ethics, 2014, 15:73. Available at: http://www.biomedcentral.com/content/pdf/1472‐6939‐15‐73.pdf

Selgelid, M. J. (2009). A moderate pluralist approach to public health policy and ethics. Public Health Ethics, 2 (2), 195–205. Available at: http://phe.oxfordjournals.org/content/2/2/195.full.pdf+html

Tannahill, A. (2008). Beyond evidence—to ethics: a decision‐making framework for health promotion, public health and health improvement. Health Promotion International, 23 (4), 380‐390. Available at: http://heapro.oxfordjournals.org/content/23/4/380.full.pdf+html

ten Have, M., van der Heide, A., Mackenbach, J., & de Beaufort, I. D. (2012). An ethical framework for the prevention of overweight and obesity: A tool for thinking through a programme’s ethical aspects. European Journal of Public Health, 23(2), 299‐305. Available at: p f , ( ),http://ejournals.ebsco.com/Direct.asp?AccessToken=46BYKY58K92PJ5PC2PB125J5YJK181CB6&Show=Object&msid=604035520Our adapted summary is available at: http://www ncchpp ca/docs/2016 eth frame tenHave En pdfhttp://www.ncchpp.ca/docs/2016_eth_frame_tenHave_En.pdf

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Selected frameworks (5)Selected frameworks (5)

Thompson A K Faith K Gibson J L & Upshur R E G (2006) Pandemic influenza preparedness: An ethicalThompson, A. K., Faith, K., Gibson, J. L., & Upshur, R. E. G. (2006). Pandemic influenza preparedness: An ethical framework to guide decision‐making. BMC Medical Ethics, 7(12). Available at: http://www.biomedcentral.com/1472‐6939/7/12

Upshur, R. E. G. (2002). Principles for the justification of public health intervention. Canadian Journal of Public Health, 93 (2), 101‐103. Available at: http://journal.cpha.ca/index.php/cjph/article/view/217Our adapted summary is available at: http://www.ncchpp.ca/docs/2016_eth_frame_upshur_En.pdf

Willison, D., Ondrusek, N., Dawson, A., Emerson, C., Ferris, L., Saginur, R., Sampson, H., & Upshur, R. E. G. (2012). A framework for the ethical conduct of public health initiatives. Public Health Ontario. Available t htt // bli h lth t i / / R it /PHO%20%20F k%20f %20Ethi l%20Cat:http://www.publichealthontario.ca/en/eRepository/PHO%20%20Framework%20for%20Ethical%20Conduct%20of%20Public%20Health%20Initiatives%20April% 202012.pdf Also, this shorter document discusses the framework and provides a table of its Ten guiding questions: Willison, D. J., Ondrusek, N., Dawson, A., Emerson, C., Ferris, L. E., Saginur, R., Sampson, H., & Upshur, R. (2014). What g p pmakes public health studies ethical? Dissolving the boundary between research and practice. BMC Medical Ethics, 15(61), 1‐6. Available at: http://bmcmedethics.biomedcentral.com/articles/10.1186/1472‐6939‐15‐61

74

Selected frameworks or supporting documents for community health ethics

Alberta Health Services. (2014). Ethics Framework: A Guide for AHS Staff, Physicians and Volunteers. Available at: http://www.albertahealthservices.ca/assets/Infofor/hp/if‐hp‐ethics‐framework.pdf

Community Ethics Network (CEN). (2008). Community Ethics Toolkit. Available at: http://www.communityethicsnetwork.ca/docs/toolkit2008.pdf

McDonald, M., Rodney, P., & Starzomski, R. (2001). A Framework for Ethical Decision‐Making: Version 6.0 Ethics Shareware. Available at: http://www ethics ubc ca/upload/A%20Framework%20for%20Ethical%20Decision‐Making pdfhttp://www.ethics.ubc.ca/upload/A%20Framework%20for%20Ethical%20Decision Making.pdf

Nova Scotia Health Ethics Network. (2015). Ethics Case Database. Available at: https://nshencases.wordpress.com/ List of resources available at: p // p /http://nshen.ca/docs/Health%20Ethics%20Resources%20for%20Website.pdf

Trillium Health Centre. (2010). IDEA Ethical Decision‐Making Framework. Guide and Worksheets. Available at: http://www.trilliumhealthcentre.org/about/documents/TrilliumIDEA_EthicalDecisionMakingFramework.pdf

75

Selected frameworks, supporting documents and resources for community health ethics (2)

Wagner, F. & Buchman, D. (2013). Ethical Decision‐making in Community Practice. (Practice examples of applying CEN Toolkit, with instruction.) Available at:https://uwaterloo.ca/school‐of‐social‐work/sites/ca.school‐of‐social‐work/files/uploads/files/ethical_decision‐making_in_community_practice.pdf

Winnipeg Regional Health Authority, Ethics Services. (2015a). Ethical Decision‐Making Framework: E id I f d P ti T l A il bl t htt // h b / t t/ i t/EIPT 037 hEvidence Informed Practice Tool. Available at: http://www.wrha.mb.ca/extranet/eipt/EIPT‐037.php

Winnipeg Regional Health Authority, Ethics Services. (2015b). Ethical Decision‐Making Framework Workbook: Evidence Informed Practice Tool Available at: http://wwwwrha mb ca/extranet/eipt/EIPTWorkbook: Evidence Informed Practice Tool. Available at: http://www.wrha.mb.ca/extranet/eipt/EIPT‐037.php

Manitoba Provincial Health Ethics Network (MB‐PHEN) Ethics Resources: Frameworks Available at:Manitoba Provincial Health Ethics Network (MB PHEN). Ethics Resources: Frameworks. Available at: http://www.mb‐phen.ca/er‐frameworks.html; Ethics Resources: Links. Available at: http://www.mb‐phen.ca/er‐links.html

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NCCHPP Resources in EthicsNCCHPP Resources in EthicsNew in 2016:Recent publications: New in 2016:

A repertoire of ethics frameworks for public health, with links to the original documents

Recent publications:

Introduction to Public Health Ethics 3: Frameworks for Public Health Ethics

A Collection of Adapted Summaries of Public Health Ethics Frameworks and Very Short Case Studies

Introduction to Public Health Ethics 2: Philosophical and Theoretical Foundations

Studies

Utilitarianism in Public Health

'P i i li ' d F k i P bli H lth

Introduction to Public Health Ethics 1: Background

Solidarity in Public Health Ethics and Practice: Its Conceptions Uses and Implications 'Principlism' and Frameworks in Public Health

EthicsConceptions, Uses and Implications

Methods of Economic Evaluation: What are the Ethical Implications for Healthy Public Policy?

For a project update with our current plans and recent publications, please visit:h // h /126/N

Web presentation:Public Health Ethics: What is it? And Why is it Important? http://www.ncchpp.ca/126/News.ccnppsImportant?

77

R fReferencesBlock, J. P. & Subramanian, S. V. (2015). Moving Beyond “Food Deserts”: Reorienting United States Policies to Reduce Disparities in

Diet Quality PLoS Med 12(12): e1001914 doi:10 1371/journal pmed 1001914 Retrieved from:Diet Quality. PLoS Med 12(12): e1001914. doi:10.1371/journal.pmed.1001914 Retrieved from: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001914

Cameron, A. J., Thornton, L. E., McNaughton, S. A., & Crawford, D. (2013). Variation in supermarket exposure to energy‐dense snack foods by socio‐economic position. Public Health Nutrition, 16(7),1178‐1185. doi: 10.1017/s1368980012002649

C di N A i ti (2006) P bli h lth i ti d thi l h ll Ethi i P ti f R i t d NCanadian Nurses Association. (2006). Public health nursing practice and ethical challenges. Ethics in Practice for Registered Nurses, February 2006, 12 pp. Ottawa: Canadian Nurses Association. Retrieved from: http://cna‐aiic.ca/~/media/cna/page‐content/pdf‐en/ethics_in_practice_jan_06_e.pdf

Cummins, S., Flint, E., & Matthews, S. A. (2014). New neighborhood grocery store increased awareness of food access but did not l di h bi b i H l h Aff i 33(2) 283 291 d i 10 1377/hl h ff 2013 0512alter dietary habits or obesity. Health Affairs, 33(2), 283‐291. doi: 10.1377/hlthaff.2013.0512

Dawson, A. (2010a). Public health ethics: Three dogmas and a cup of hemlock. Bioethics, 24(5), 218‐225.Dawson, A. (2010b). Theory and practice in public health ethics: A complex relationship. In S. Peckham & A. Hann (Eds.), Public

Health Ethics and Practice. Bristol: The Policy Press. Farley, T. A., Rice, J., Bodor, J. N., Cohen, D. A., Bluthenthal R. N., & Rose, D. (2009). Measuring the food environment: shelf space

of fruits, vegetables, and snack foods in stores. Journal of Urban Health, 86(5), 672‐82. doi: 10.1007/s11524‐009‐9390‐3Government of Manitoba. (2016). What you should know about bed bugs / Who is responsible for bed bug control? Retrieved on

February 10, 2016 from: http://www.gov.mb.ca/bedbugs/index.htmleb ua y 0, 0 6 o p // go b ca/bedbugs/ deGovernment of Manitoba. (2010). Families First Program Evaluation Report. Retrieved from:

http://www.gov.mb.ca/healthychild/familiesfirst/ff_eval2010.pdfMacDonald, M. (2015). Introduction to Public Health Ethics 3 ‐ Frameworks for Public Health Ethics. Montréal, Québec: National

Collaborating Centre for Healthy Public Policy Retrieved from:Collaborating Centre for Healthy Public Policy. Retrieved from: http://www.ncchpp.ca/127/Publications.ccnpps?id_article=1426

Morestin, F. & Castonguay, J. (2013). Constructing a logic model for a healthy public policy: why and how? Montréal, Québec: National Collaborating Centre for Healthy Public Policy. Retrieved from: http://www ncchpp ca/172/publications ccnpps?id article=898http://www.ncchpp.ca/172/publications.ccnpps?id_article=898

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R f 2References, 2Nicholson, K. & Marcoux, J. (Dec 2, 2015). Buying groceries a long trek for family in Winnipeg food desert. Winnipeg: CBC , , ( , ) y g g g f f y p g f p g

News. Retrieved from: http://www.cbc.ca/news/canada/manitoba/buying‐groceries‐a‐long‐trek‐for‐family‐in‐winnipeg‐food‐desert‐1.3345126

Nixon, S. (2005). Critical public health ethics and Canada’s role in global health. Canadian Journal of Public Health, 97(1), 32‐34.

Silver J (2015) Spatially concentrated racialized poverty as a social determinant of health: The case of Winnipeg’s innerSilver, J. (2015). Spatially concentrated, racialized poverty as a social determinant of health: The case of Winnipeg s inner city. In L. Fernandez, S. MacKinnon, & J. Silver (Eds.), The Social Determinants of Health in Manitoba, 2nd ed. Winnipeg: Canadian Centre for Policy Alternatives, Manitoba Office.

Smirl, E. (2015). Shifting the tables: From food insecurity to food sovereignty in Manitoba. In L. Fernandez, S. MacKinnon, & J. Silver (Eds.), The Social Determinants of Health in Manitoba, 2nd ed. Winnipeg: Canadian Centre for Policy Alternatives Manitoba OfficeAlternatives, Manitoba Office.

ten Have, M., van der Heide, A., Mackenbach, J., & de Beaufort, I. D. (2012). An ethical framework for the prevention of overweight and obesity: A tool for thinking through a programme’s ethical aspects. European Journal of Public Health, 23(2), 299‐305. Available at:

Winnipeg Regional Health Authority. (2013). Health for all: Building Winnipeg’s health equity action plan. Winnipeg: Wi i R i l H lth A th itWinnipeg Regional Health Authority.

Winnipeg Regional Health Authority, Ethics Services. (2015a). Ethical decision‐making framework: Evidence informed practice tool. Retrieved from: http://www.wrha.mb.ca/extranet/eipt/EIPT‐037.php

Winnipeg Regional Health Authority, Ethics Services. (2015b). Ethical decision‐making framework workbook: Evidence informed practice tool. Retrieved from: http://www.wrha.mb.ca/extranet/eipt/EIPT‐037.phpf p p p p p

Winnipeg Regional Health Authority. (2015c). Public Health Nurse Orientation Checklist. Winnipeg: Winnipeg Regional Health Authority. Retrieved from:http://www.wrha.mb.ca/extranet/publichealth/files/PHNOrientChecklistMar2015.pdf

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Thanks for joining usj g

You’re interested in this topic? Visit us at www.ncchpp.ca for more resources

Michael Keeling & Olivier BellefleurNational Collaborating Centre for Healthy Public Policy

i h l k li @i li i b ll fl @[email protected] [email protected]

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Documents

Ethics in Community and Public Health – From …Subsidy for new full‐service grocery stores and supermarkets Your health unit has been asked to review the city’s Healthy Food