Making Good Public Health PolicyJessica Berg, JD, MPHProfessor of Law, Bioethics & Public HealthCase Western Reserve University March 27, 2012

Goals

•Identify what counts as “policy”

•Discuss the skills and background needed to develop good public health policy

•Describe an approach to teaching these skills

What is policy?

•Guiding principle•A way of doing things•Guidance toward attainment of goals•Stated position on a matter•Course of action adopted or pursued•Measures adopted to achieve ends•Authoritative guidelines or decisions

Oxford English Dictionary

What counts as Public Health?

BP Oil Spill

National Drug Control Strategy & Drug Shortages

Infant Morality

Gun Control

Public Health Policy includes:

•Health-related decisions made by legislators that are codified into law

•Rules/regulations to implement legislation or operate government and health-related programs

•Judicial decisions related to health•Some private organization policies

Longest (1998)

• Central to organization of PH agencies

• Central to understanding what PH agencies and professionals are authorized to do

• Crucial for proposing and evaluating health policy

*Need to have general understanding of legal system and public health laws to know when to get more information

Importance of Studying Law

PH Organization and Structure

• Federal Structure▫Federal Legislation▫Federal Agencies

• State Structure▫State Legislation (Health Code)▫State Department of Health

• Local structure▫Centralized, decentralized or hybrid▫Local Health Board (volunteer, appointed,

elected)▫Ordinances

•Do you report to the mayor, a local board of health, or a state health department official?

•Where can you get legal advice?

• If you need to enforce a law do you go to the sheriff's department, the city police department, the state police department?

•What powers are authorized at what level?

Examples

•Licensing•Confidentiality and Reporting Obligations•Authority (police power)

▫Permits▫Nuisance Orders

Orders to Cease & Desist, Liens, Prosecutions

▫Subpoena records▫Isolation, quarantine, detention

Law and PH Professionals

•May you reveal HIV status of a county employee?

•Do you have the authority to quarantine a building in an infectious disease case?

•Can you issue a permit for a temporary food service for a charitable event?

•Under what circumstances can you issue an isolation order for a noncompliant homeless MDR-TB patient?

Examples

•What do we expect to accomplish?

•Is the policy appropriate?▫ Does it reduce aggregate health risks?▫ Are there less intrusive means?

•Range of legal interventions available

•Implications of our choice:▫Individual rights▫Allocation of public resources▫Unanticipated effects

Legal Issues in Evaluation of Policy

Soda Taxes

Trans Fat Bans

NSLP Rules

Phys Ed Mandates

Law Summary• Need to know:

▫ Basics of legal system, implications for PH organization, professional responsibility, and authority

▫ Circumstances that require accessing legal expertise

▫ Range of legal tools Educate, create incentives, deter behavior, punish

individuals or companies Require safer product design Alter the informational, physical, social or economic

environment

• Interplay with Ethics

Importance of Studying Ethics in Developing Good PH Policy

•Increase your ability to recognize ethical issues

•Develop analytical skills in ethics

•Minimize potential ethical distress when you face difficult cases

•Enhance your ability to practice public health

Types of Ethics• Regulatory and Policy

▫ Moral weight of community health▫ Public Accountability▫ Social Justice and Human Rights

• Professional and Organizational Ethics▫ APHA Code of Ethics▫ Importance and Limits of Advocacy

• Theoretical

• Applied

Ethical Theories = Tools•Consequentialist (Utilitarianism)•Deontological (Kant, Rawls)•Principlism (Beauchamp & Childress)•Liberal Individualism•Communitarianism•Natural law/ Religion•Virtue Ethics (Aristotle)•Casuistry

Examples

•Vaccine distribution in shortage

•Restrictions on travel due to infectious disease

•Determining whether to withdraw an efficacious drug from the market because of safety concerns

•Limited funds for research vs. surveillance, and determining which populations should be studied.

•Need to understand:▫Professional ethical obligations▫Types of ethical theories and their

limitations▫How to identify ethical issues

•Interplay with law

Ethics Summary

Bernard Schoenbaum ID: 29443,The New Yorker 11/30/1992

Step 1: Lay the Groundwork

•Basics of Political System

•Basics of Legal System

•Basics of Health Economics

•Basics of Public Health System (including Health Delivery System)

Step 2: Practice

•Policy Brief▫Statement▫Background▫Landscape▫Options▫Analysis▫Recommendation

•Format, Length, Feedback, Goal

Step 3: Provide Additional Background on Implementation

•Health Management Background▫Management Theories▫Organizational Behavior▫Conflict Resolution▫Human Resources▫Financial Principles

Accounting and Budgeting

Step 4: Apply What You’ve Learned•Team Project

▫Choose an option to implement▫Identify steps necessary for implementation▫Identify potential barriers▫Basic cost analysis/budget▫Work together to present/teach/advocate

Bernard Schoenbaum, ID: 2859, The New Yorker