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![Pauly et al. BMC Public Health (2021) 21:1567
https://doi.org/10.1186/s12889-021-11594-y
RESEARCH ARTICLE
"The health equity curse": ethical tensions
in promoting health equity
Bernie Pauly', Tina Revai?, Lenora Marcellus, Wanda Martin, Kathy Easton and Marjorie MacDonald'
Abstract
Background: Public health (PH) practitioners have a strong moral commitment to health equity and social justice.
However, PH values often do not align with health systems values, making it challenging for PH practitioners to
promote health equity. In spite of a growing range of PH ethics frameworks and theories, little is known about
ethical concerns related to promotion of health equity in PH practice. The purpose of this paper is to examine the
ethical concerns of PH practitioners in promoting health equity in the context of mental health promotion and
prevention of harms of substance use.
Methods: As part of a broader program of public health systems and services research, we interviewed 32 PH
practitioners.
Results: Using constant comparative analysis, we identified four systemic ethical tensions: [1] biomedical versus
social determinants of health agenda; [2] systems driven agendas versus situational care; [3] stigma and
discrimination versus respect for persons; and [4] trust and autonomy versus surveillance and social control.
Conclusions: Naming these tensions provides insights into the daily ethical challenges of PH practitioners and an
opportunity to reflect on the relevance of PH frameworks. These findings highlight the value of relational ethics as
a promising approach for developing ethical frameworks for PH practice.
Background
Health inequities result from an unequal distribution of
the determinants of health, disadvantaging those who
lack wealth, power or prestige [1, 2]. Health inequities
increase as social position decreases [3, 4]. As social po-
sitioning decreases, the higher the concentration of
harms from illicit substance use, poor mental health, un-
met health care needs, and difficulties accessing health
care [5, 6]. These harms often intersect with, and are ex-
acerbated by, the stigma and discrimination associated
with drug use, mental illness, poverty, and marginalized
social location further affecting health and well-being
Keywords: Health equity, Relational ethics, Stigma and discrimination, Mental health promotion, Prevention of
substance use harms
*Corespondence: wanda.martin@usask.ca
*College of Nursing, University of Saskatchewan, Health Science
Building-1A10, Box 6, 107 Wiggins Road, Saskatoon, SK S7N 5E5, Canada
Full list of author information is available at th
end of the article
BMC
Pauly et al. BMC Public Health
BMC Public Health
Open Access
(2021) 21:1567
The twin moral aims of public health are to promote
population health and reduce health inequities [13,
Promoting health equity and social justice are part of the
ontological foundation of public health (PH) [15-17].
Barrett et al. [18] specifically highlights health equity as
an important area of concern for PH ethics. Although
there are strong national and international commitments
to health equity as a key goal of health systems and ser-
vices [19, 20], the degree to which organized health sys-
tems actually undertake these moral aims is contested
[21, 22]. Delivering health services is a complex process
en Access This on a
2021 Open Ac
This article is licensed under a Creative Commons Attribution 40 International License,
which is us, sharing, adaptation, distribution and reproduction in any madium or format, as long as you g
were made the images or other third party material in this artide are included in the artide's Cave Commons
Iranted the ind Inn in the material material is not included in the ancle's Creative Commons
licence and your intended use is not permitted by statutory saqulation or exceeds the permited use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/
The Creative Commons Public Domain Dedication walver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
the
recognizing that these frameworks should inform prac
tice with the reverse also being true. Past investigations
of ethics in public health practice have identified issues
related to collaboration, priority setting, resource alloca-
tion and decision making [50-52]. We found one study
of public health decision makers and health equity [53]
but none that focus explicitly on public health practi-
tioners and promotion of health equity. A better under-
standing of the ethical concerns of PH practitioners
specifically in relation to their efforts to reduce health
inequities is essential to inform frameworks that are
relevant and attuned to development of ethical and more
equitable PH decision-making and practice.
Methods
This study is one of four interrelated studies in a
broader program of public health systems and services
research with an overarching aim to generate knowledge
about the integration of an equity lens in PH during a
time of PH system renewal in the province of British
Columbia (BC), Canada [54]. The PH areas of mental
health promotion and the prevention of harms of sub-
stance use were the focus of a constructivist grounded
theory study to explore the process of how PH practi-
tioners navigate health equity work [55, 56]. As part of
this grounded theory, we identified a range of ethical is-
sues in the promotion of health equity. Understanding
these issues is an important starting point for under-
standing the process of navigating health equity work.
This study received ethical approval from the University
of Victoria, University of Saskatchewan, and six partici-
pating Health Authorities (HA) (REB# H11-03359). We
obtained written consent from participants.
Sampling and data gathering
We used purposive and snowball sampling in collab-
oration with HA partners to identify PH practitioners
with PH responsibilities for mental health promotion
and prevention of harms of substance use in their
work. The sample consisted of 32 participants with
whom we conducted 29 semi-structured interviews
(face-to-face and phone) and one focus group of 3
people. We developed the interview guide for this
study, and it is available as a supplemental file. Partic-
ipants represented five regional HAs and one Provin-
cial Health Authority. Participants had, on average,
10.26 years of PH experience. Registered nurses (RNS)
were the majority of participants [25] and all but one
had post-secondary education. Interviews averaged 60
min and were recorded and transcribed verbatim by
an experienced transcriptionist and verified by the
study research assistant.
[7-11]. In such situations, the promotion of health
equity raises questions of justice related to the structural
conditions that create inequities, such as who has access
to resources for health and how structural disadvantages
limit access [12].
Page 3 of 11
Data analysis
We employed constant comparative analysis, a method
foundational grounded theory and an accepted ap-
proach to qualitative enquiry [57-59]. This method in-
volves detailed coding to develop concepts and
relationships among the codes by comparing incident-
to-incident, incident-to concept, and concept-to-concept
to take the analysis from the "ground" up through higher
levels of abstraction [60]. Our team of five researchers
(four faculty and one research assistant) generated a set
of inductive codes for the coding framework from line-
by-line coding of the initial three interviews. The re-
search assistant continued coding the interviews line-by-
line using the initially developed framework and adding
to the coding structure using NVivo software. The team
conducted in-depth analytic discussions to compare inci-
dents within the same interview, across interviews, and
over time to establish relationships and differences be-
tween incidents and concepts [55, 60]. We employed
memoing, diagramming, and reflexivity in the concep-
tual development of the key themes and to enhance
rigor. The eventual grounded theory (GT) is reported
elsewhere [56]. In this paper, we describe in depth one
element of the grounded theory the specific ethical
tensions identified by PH practitioners that arose from
their practice promoting mental health and preventing
harms of substance use.
Results
Participants identified four systemic ethical tensions: [1]
biomedical versus social determinants of health agenda;
[2] systems driven agendas versus situational care; [3]
stigma and discrimination versus respect for persons;
and [4] choice and autonomy versus surveillance and so-
cial control. In describing these r tensions, we lay out
the full range of ethical issues expressed by participants
as a group. The extent to
at to which individual participants
were aware of or described these tensions varied across
participants. While some titioners xpressed a high
degree of awareness of a range of issues, other practi-
tioners were less aware of the broad range of ethical is-
sues related to health equity work. So, the lens for
viewing what constituted an ethical issue in health equity
work varied across participants. As described elsewhere
[56], PH practitioners with a critical public health lens'
were more likely to recognize and experience ethical
tensions. For each of these ethical tensions, we describe
the underlying values conflict and identify the ethical
concerns from the perspectives of PH practitioners. Al-
though we present each of the four areas of ethical ten-
sions separately, they are interrelated, and PH
practitioners often must simultaneously navigate these
issues to promote health equity.
Pauly et al. BMC Public Health
(2021) 21:1567
with significant political and economic influences and
multiple competing demands. However, while PH has an
obligation to promote health equity, doing so within a
health system that does not prioritize health equity is
challenging and a source of ethical tensions that are
often not well articulated [23].
In British Columbia, Canada, calls for PH system re
newal led to the development of a framework for core
functions in public health [24] and later the guiding PH
framework [25]. Both the core functions and guiding PH
frameworks include a directive to apply a health equity
lens in all PH programs. Of the 21 core programs, our
PH knowledge user partners identified mental health
promotion and prevention of harms of substance use as
two important areas to understand and learn about the
application of a health equity lens and the ethical issues
encountered in promoting health equity. The purpose of
this article is to describe and discuss the ethical tensions
experienced by PH practitioners with obligations to pro-
mote health equity in the core public health areas of
mental health promotion and prevention of harms of
substance use. We begin with some background on PH
ethics followed by a description of the study method-
ology and then present and discuss findings related to
four key ethical issues experienced by PH practitioners.
There are a range of ethical issues identified in the PH
literature related to infectious disease control, emer-
gency preparedness, public health communication, cost-
effective decision-making and more [18, 26]. For coun-
tries without universal healthcare, the lack of universal
insurance and the uninsured are key ethical and health
equity concerns [27]. Although Canada has a system of
universal health care for accessing doctors and hospitals,
health inequities in Canada are growing and PH pro-
viders often work in health systems that are not aligned
with PH values of social justice or address the broader
determinants of health [28-31].
Historically, bioethics has focused on individual rela-
tionships and clinical biomedical issues concerned with
"right" courses of action primarily in acute care settings
with a lack of attention to ethical issues in public health
[32]. Furthermore, dominant bioethical frameworks that
focus on individuals and biomedical issues do not ad-
dress PH ethical concerns adequately [33-35]. Thus, PH
ethics is developing distinct from clinical bioethics with
a focus on beneficence, respect for persons, and justice
[36-40]. Unlike clinical bioethics, PH ethics: [1] con-
cerns populations, public policy a d policy structures ra
ther than individuals; [2] places equity at the forefront;
[3] includes actors outside the healthcare sector, [4] fo-
cuses on prevention of illness and disease, and health
promotion [41].
Several authors have proposed health equity as foun-
dational to PH ethics [13, 15-17, 42]. Dan Beauchamp
Pauly et al. BMC Public Health (2021) 21:1567
Theme 1: the health equity curse: biomedical versus
social determinants of health agenda
Participants identified a primary area of ethical tension
as the dominance of a biomedical agenda that obscured
the PH focus on health equity, with a subsequent lack of
focus on the social determinants of health and systemic
responses to reduce health inequities. They defined the
biomedical agenda as the dominance of acute care prior-
ities with a consequent emphasis on the treatment of
disease, illness and injury for individuals rather than pre-
vention and promotion. The following participant work
ing on an integrated outreach team describes:
We've got the swing how to get people tested to make
sure that the medication is working for them. So the
medical system is actually quite good, quite slick.
But in terms of the support for the other parts of
their sort of hierarchy of needs, the housing, the food,
you know all the stability that goes along with, or in-
stability that goes along with poverty, I think we are
still a long way from sorting that out. (S4-29)
Participants observed that within a biomedical system,
there is a lack of understanding and valuing of PH work
especially the work of prevention.
It's really hard to say we prevented this mom from
harming her baby, or we prevented this mom from
having a postpartum psychosis and going into a hos-
pital... it's really hard to say we prevented some
thing from happening. And so, you know, money and
hospitals, people can see when they're voting or put
ting money into the healthcare system, they can say,
okay this x-ray machine does x-rays that prevents
pneumothorax, which prevents death. Right? So
that's an easy thing for people to see, but in preven-
tion and health promotion, it's really hard to say,
you know, having these clinics will prevent something
from happening because the outcome should be
nothing. And it's hard to prove nothing. (S4-
04)
Furthermore, participants highlighted that even within
PH what seemed to matter was communicable disease
prevention and a focus on secondary prevention with
less attention to primary prevention or health promotion
such as described by the participant above.
And so the (name of organization) says that they're
into health equity, and they say they understand so
cial determinants of health, but if you look at every
thing they do and all of their work plans and stuff.
they're all about some bugs and viruses, and emer-
gency, you know, Ebola responses ....That seems to
Page 2 of 11
wrote "public health should be a way of doing justice" (
[17] p. 8) identifying that public health is social justice.
[43] applies Rawls' approach to justice as fair soci-
to argue that social inequalities are wrong when
stem from unjust social, political and economic in-
stitutions. He states further, "it thus embeds the pursuit.
of health equity in the pursuit of social justice in gen-
eral" (p.160). Faden and Powers offer "a non-ideal theory
of justice, intended to offer practical guidance on ques-
tions of which inequalities matter most when just back
ground conditions are not in place" ([16] p. 30). Their
Twin Aim Theory of Social Justice [44, 45] explicates six
elements of well-being as criteria for procedural justice
at the level of the individual, whilst simultaneously ad-
dressing the design and reform of social arrangements to
guard against systematic patterns of injustice. Their
work sketches out normative ethical guidance for policy
makers [16].
As Peter [43] points out, Rawls did not include health
as a primary good but did include self-respect as an im-
portant primary good and that if certain social positions
are devalued "such that people cannot gain a sense of
self-respect, then these structures are unjust" (p.167).
Jennings [46] draws attention to political theory and re-
lational interpretations of agency, autonomy, and justice
as well as values of collectivity, equal respect, parity of
voice, mutuality, and solidarity as important to concep-
tions of PH ethics. Baylis, Kenny and Sherwin's [15] and
Kenny Sherwin and Baylis [42] conception of PH ethics
emphasizes solidarity and the public good. Using rela-
tional theory, these authors see individuals as inter-
dependent and socially, politically, and economically
situated. Rather than listing a hierarchy of principles,
where independent autonomy is privileged [47], this ap-
proach holds competing ethical issues in tension towards
the interdependent aim of the public's health, while rec-
ognizing that persons are not all equally situated in rela-
tion to opportunities for health [42]. Thus, recognizing
the many ways in which persons can be differentially
constrained based on different social locations. The PH
practitioner's task is to make visible the impacts that re-
sult from policy and healthcare decisions with a view to
equitably balancing competing demands amongst differ-
ently situated social groups.
However, to develop normative guidance for PH, it is
critical to ground ethical theory and perspectives in the
everyday ethical concerns that arise for practitioners
Applied ethicists Leget, Borry and DeVries [49]
argue that a critical ethical approach integrating empir-
ical research and normative ethical theory can clarify is-
sues and has the potential to set the conditions for
supporting real world practice through an ongoing dia-
lectical process. Thus, there is a role for research in
shaping the development of ethical frameworks
Page 4 of 11
be the level of where we sit with health equity and
they don't know how to talk about or they don't
publicly talk about what health has to say about the
the systemic stuff that we have, our policies that
create health inequity. (S4-02)
While participants recognized that the health system
was not solely responsible for addressing the determi-
nants of health, the lack of value for the PH role and fo-
cusing upstream on the root causes of health inequities
were often described by participants as unimportant to
health systems. This same participant describes the daily
ethical challenges of working in health care organiza-
tions that do not embrace health equity:
We're ethically challenged every day because we
work in health care in a place where people don't
have adequate services, don't get treated well in the
system, don't have proper housing. So, sort of a dif
ferent level for me. I was just going to say.... once
you start seeing the world through a social determi-
nants lens, it's like you're- you can never go back
and it's a bit of a curse. It's not easy. (S4-02)
Other participants also shared that once you saw the
world through a health equity lens it raised more ethical
challenges than if you did not, because it means living
with the moral discomfort of knowing what is needed
but being unable to act. They acknowledged that some-
mes it was easier for them and their colleagues not to
hold a health equity lens because accepting the status
quo reduces discomfort. This paradoxical "health equity
curse" included knowing that clients, families, groups,
communities and populations are experiencing deficits
in resources for health but their needs do not fit into the
dominant model of biomedical care.
This lack of access to resources for health was a fun-
damental ethical issue and experienced as morally dis-
tressing, as described by the following participant:
Because you know, you're stuck you can't give
people a better house......You can't get them a sink,
you can't give them the basic needs, right? So you
are, you're very torn and almost feel guilty at the
end of the day when you go home and you think, like
"God," you know? You stand in question of what you
have and what you need, and what people need in
society. (S4-20)
Working within a healthcare system that fails to act on
the determinants of health weighed heavily on the PH
practitioners in our study. They felt that they had few, if
any, resources available to address determinants of
health or the structural causes that produced health.](/v2/_next/image?url=https%3A%2F%2Fcontent.bartleby.com%2Fqna-images%2Fquestion%2Fac3be618-b645-4bd8-855b-808ff3fc18d4%2F7b3976be-cdf7-4d0b-819e-3ca1af5d0f03%2F0po7zbl_processed.png&w=3840&q=75)
Transcribed Image Text:Pauly et al. BMC Public Health (2021) 21:1567
https://doi.org/10.1186/s12889-021-11594-y
RESEARCH ARTICLE
"The health equity curse": ethical tensions
in promoting health equity
Bernie Pauly', Tina Revai?, Lenora Marcellus, Wanda Martin, Kathy Easton and Marjorie MacDonald'
Abstract
Background: Public health (PH) practitioners have a strong moral commitment to health equity and social justice.
However, PH values often do not align with health systems values, making it challenging for PH practitioners to
promote health equity. In spite of a growing range of PH ethics frameworks and theories, little is known about
ethical concerns related to promotion of health equity in PH practice. The purpose of this paper is to examine the
ethical concerns of PH practitioners in promoting health equity in the context of mental health promotion and
prevention of harms of substance use.
Methods: As part of a broader program of public health systems and services research, we interviewed 32 PH
practitioners.
Results: Using constant comparative analysis, we identified four systemic ethical tensions: [1] biomedical versus
social determinants of health agenda; [2] systems driven agendas versus situational care; [3] stigma and
discrimination versus respect for persons; and [4] trust and autonomy versus surveillance and social control.
Conclusions: Naming these tensions provides insights into the daily ethical challenges of PH practitioners and an
opportunity to reflect on the relevance of PH frameworks. These findings highlight the value of relational ethics as
a promising approach for developing ethical frameworks for PH practice.
Background
Health inequities result from an unequal distribution of
the determinants of health, disadvantaging those who
lack wealth, power or prestige [1, 2]. Health inequities
increase as social position decreases [3, 4]. As social po-
sitioning decreases, the higher the concentration of
harms from illicit substance use, poor mental health, un-
met health care needs, and difficulties accessing health
care [5, 6]. These harms often intersect with, and are ex-
acerbated by, the stigma and discrimination associated
with drug use, mental illness, poverty, and marginalized
social location further affecting health and well-being
Keywords: Health equity, Relational ethics, Stigma and discrimination, Mental health promotion, Prevention of
substance use harms
*Corespondence: wanda.martin@usask.ca
*College of Nursing, University of Saskatchewan, Health Science
Building-1A10, Box 6, 107 Wiggins Road, Saskatoon, SK S7N 5E5, Canada
Full list of author information is available at th
end of the article
BMC
Pauly et al. BMC Public Health
BMC Public Health
Open Access
(2021) 21:1567
The twin moral aims of public health are to promote
population health and reduce health inequities [13,
Promoting health equity and social justice are part of the
ontological foundation of public health (PH) [15-17].
Barrett et al. [18] specifically highlights health equity as
an important area of concern for PH ethics. Although
there are strong national and international commitments
to health equity as a key goal of health systems and ser-
vices [19, 20], the degree to which organized health sys-
tems actually undertake these moral aims is contested
[21, 22]. Delivering health services is a complex process
en Access This on a
2021 Open Ac
This article is licensed under a Creative Commons Attribution 40 International License,
which is us, sharing, adaptation, distribution and reproduction in any madium or format, as long as you g
were made the images or other third party material in this artide are included in the artide's Cave Commons
Iranted the ind Inn in the material material is not included in the ancle's Creative Commons
licence and your intended use is not permitted by statutory saqulation or exceeds the permited use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/
The Creative Commons Public Domain Dedication walver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
the
recognizing that these frameworks should inform prac
tice with the reverse also being true. Past investigations
of ethics in public health practice have identified issues
related to collaboration, priority setting, resource alloca-
tion and decision making [50-52]. We found one study
of public health decision makers and health equity [53]
but none that focus explicitly on public health practi-
tioners and promotion of health equity. A better under-
standing of the ethical concerns of PH practitioners
specifically in relation to their efforts to reduce health
inequities is essential to inform frameworks that are
relevant and attuned to development of ethical and more
equitable PH decision-making and practice.
Methods
This study is one of four interrelated studies in a
broader program of public health systems and services
research with an overarching aim to generate knowledge
about the integration of an equity lens in PH during a
time of PH system renewal in the province of British
Columbia (BC), Canada [54]. The PH areas of mental
health promotion and the prevention of harms of sub-
stance use were the focus of a constructivist grounded
theory study to explore the process of how PH practi-
tioners navigate health equity work [55, 56]. As part of
this grounded theory, we identified a range of ethical is-
sues in the promotion of health equity. Understanding
these issues is an important starting point for under-
standing the process of navigating health equity work.
This study received ethical approval from the University
of Victoria, University of Saskatchewan, and six partici-
pating Health Authorities (HA) (REB# H11-03359). We
obtained written consent from participants.
Sampling and data gathering
We used purposive and snowball sampling in collab-
oration with HA partners to identify PH practitioners
with PH responsibilities for mental health promotion
and prevention of harms of substance use in their
work. The sample consisted of 32 participants with
whom we conducted 29 semi-structured interviews
(face-to-face and phone) and one focus group of 3
people. We developed the interview guide for this
study, and it is available as a supplemental file. Partic-
ipants represented five regional HAs and one Provin-
cial Health Authority. Participants had, on average,
10.26 years of PH experience. Registered nurses (RNS)
were the majority of participants [25] and all but one
had post-secondary education. Interviews averaged 60
min and were recorded and transcribed verbatim by
an experienced transcriptionist and verified by the
study research assistant.
[7-11]. In such situations, the promotion of health
equity raises questions of justice related to the structural
conditions that create inequities, such as who has access
to resources for health and how structural disadvantages
limit access [12].
Page 3 of 11
Data analysis
We employed constant comparative analysis, a method
foundational grounded theory and an accepted ap-
proach to qualitative enquiry [57-59]. This method in-
volves detailed coding to develop concepts and
relationships among the codes by comparing incident-
to-incident, incident-to concept, and concept-to-concept
to take the analysis from the "ground" up through higher
levels of abstraction [60]. Our team of five researchers
(four faculty and one research assistant) generated a set
of inductive codes for the coding framework from line-
by-line coding of the initial three interviews. The re-
search assistant continued coding the interviews line-by-
line using the initially developed framework and adding
to the coding structure using NVivo software. The team
conducted in-depth analytic discussions to compare inci-
dents within the same interview, across interviews, and
over time to establish relationships and differences be-
tween incidents and concepts [55, 60]. We employed
memoing, diagramming, and reflexivity in the concep-
tual development of the key themes and to enhance
rigor. The eventual grounded theory (GT) is reported
elsewhere [56]. In this paper, we describe in depth one
element of the grounded theory the specific ethical
tensions identified by PH practitioners that arose from
their practice promoting mental health and preventing
harms of substance use.
Results
Participants identified four systemic ethical tensions: [1]
biomedical versus social determinants of health agenda;
[2] systems driven agendas versus situational care; [3]
stigma and discrimination versus respect for persons;
and [4] choice and autonomy versus surveillance and so-
cial control. In describing these r tensions, we lay out
the full range of ethical issues expressed by participants
as a group. The extent to
at to which individual participants
were aware of or described these tensions varied across
participants. While some titioners xpressed a high
degree of awareness of a range of issues, other practi-
tioners were less aware of the broad range of ethical is-
sues related to health equity work. So, the lens for
viewing what constituted an ethical issue in health equity
work varied across participants. As described elsewhere
[56], PH practitioners with a critical public health lens'
were more likely to recognize and experience ethical
tensions. For each of these ethical tensions, we describe
the underlying values conflict and identify the ethical
concerns from the perspectives of PH practitioners. Al-
though we present each of the four areas of ethical ten-
sions separately, they are interrelated, and PH
practitioners often must simultaneously navigate these
issues to promote health equity.
Pauly et al. BMC Public Health
(2021) 21:1567
with significant political and economic influences and
multiple competing demands. However, while PH has an
obligation to promote health equity, doing so within a
health system that does not prioritize health equity is
challenging and a source of ethical tensions that are
often not well articulated [23].
In British Columbia, Canada, calls for PH system re
newal led to the development of a framework for core
functions in public health [24] and later the guiding PH
framework [25]. Both the core functions and guiding PH
frameworks include a directive to apply a health equity
lens in all PH programs. Of the 21 core programs, our
PH knowledge user partners identified mental health
promotion and prevention of harms of substance use as
two important areas to understand and learn about the
application of a health equity lens and the ethical issues
encountered in promoting health equity. The purpose of
this article is to describe and discuss the ethical tensions
experienced by PH practitioners with obligations to pro-
mote health equity in the core public health areas of
mental health promotion and prevention of harms of
substance use. We begin with some background on PH
ethics followed by a description of the study method-
ology and then present and discuss findings related to
four key ethical issues experienced by PH practitioners.
There are a range of ethical issues identified in the PH
literature related to infectious disease control, emer-
gency preparedness, public health communication, cost-
effective decision-making and more [18, 26]. For coun-
tries without universal healthcare, the lack of universal
insurance and the uninsured are key ethical and health
equity concerns [27]. Although Canada has a system of
universal health care for accessing doctors and hospitals,
health inequities in Canada are growing and PH pro-
viders often work in health systems that are not aligned
with PH values of social justice or address the broader
determinants of health [28-31].
Historically, bioethics has focused on individual rela-
tionships and clinical biomedical issues concerned with
"right" courses of action primarily in acute care settings
with a lack of attention to ethical issues in public health
[32]. Furthermore, dominant bioethical frameworks that
focus on individuals and biomedical issues do not ad-
dress PH ethical concerns adequately [33-35]. Thus, PH
ethics is developing distinct from clinical bioethics with
a focus on beneficence, respect for persons, and justice
[36-40]. Unlike clinical bioethics, PH ethics: [1] con-
cerns populations, public policy a d policy structures ra
ther than individuals; [2] places equity at the forefront;
[3] includes actors outside the healthcare sector, [4] fo-
cuses on prevention of illness and disease, and health
promotion [41].
Several authors have proposed health equity as foun-
dational to PH ethics [13, 15-17, 42]. Dan Beauchamp
Pauly et al. BMC Public Health (2021) 21:1567
Theme 1: the health equity curse: biomedical versus
social determinants of health agenda
Participants identified a primary area of ethical tension
as the dominance of a biomedical agenda that obscured
the PH focus on health equity, with a subsequent lack of
focus on the social determinants of health and systemic
responses to reduce health inequities. They defined the
biomedical agenda as the dominance of acute care prior-
ities with a consequent emphasis on the treatment of
disease, illness and injury for individuals rather than pre-
vention and promotion. The following participant work
ing on an integrated outreach team describes:
We've got the swing how to get people tested to make
sure that the medication is working for them. So the
medical system is actually quite good, quite slick.
But in terms of the support for the other parts of
their sort of hierarchy of needs, the housing, the food,
you know all the stability that goes along with, or in-
stability that goes along with poverty, I think we are
still a long way from sorting that out. (S4-29)
Participants observed that within a biomedical system,
there is a lack of understanding and valuing of PH work
especially the work of prevention.
It's really hard to say we prevented this mom from
harming her baby, or we prevented this mom from
having a postpartum psychosis and going into a hos-
pital... it's really hard to say we prevented some
thing from happening. And so, you know, money and
hospitals, people can see when they're voting or put
ting money into the healthcare system, they can say,
okay this x-ray machine does x-rays that prevents
pneumothorax, which prevents death. Right? So
that's an easy thing for people to see, but in preven-
tion and health promotion, it's really hard to say,
you know, having these clinics will prevent something
from happening because the outcome should be
nothing. And it's hard to prove nothing. (S4-
04)
Furthermore, participants highlighted that even within
PH what seemed to matter was communicable disease
prevention and a focus on secondary prevention with
less attention to primary prevention or health promotion
such as described by the participant above.
And so the (name of organization) says that they're
into health equity, and they say they understand so
cial determinants of health, but if you look at every
thing they do and all of their work plans and stuff.
they're all about some bugs and viruses, and emer-
gency, you know, Ebola responses ....That seems to
Page 2 of 11
wrote "public health should be a way of doing justice" (
[17] p. 8) identifying that public health is social justice.
[43] applies Rawls' approach to justice as fair soci-
to argue that social inequalities are wrong when
stem from unjust social, political and economic in-
stitutions. He states further, "it thus embeds the pursuit.
of health equity in the pursuit of social justice in gen-
eral" (p.160). Faden and Powers offer "a non-ideal theory
of justice, intended to offer practical guidance on ques-
tions of which inequalities matter most when just back
ground conditions are not in place" ([16] p. 30). Their
Twin Aim Theory of Social Justice [44, 45] explicates six
elements of well-being as criteria for procedural justice
at the level of the individual, whilst simultaneously ad-
dressing the design and reform of social arrangements to
guard against systematic patterns of injustice. Their
work sketches out normative ethical guidance for policy
makers [16].
As Peter [43] points out, Rawls did not include health
as a primary good but did include self-respect as an im-
portant primary good and that if certain social positions
are devalued "such that people cannot gain a sense of
self-respect, then these structures are unjust" (p.167).
Jennings [46] draws attention to political theory and re-
lational interpretations of agency, autonomy, and justice
as well as values of collectivity, equal respect, parity of
voice, mutuality, and solidarity as important to concep-
tions of PH ethics. Baylis, Kenny and Sherwin's [15] and
Kenny Sherwin and Baylis [42] conception of PH ethics
emphasizes solidarity and the public good. Using rela-
tional theory, these authors see individuals as inter-
dependent and socially, politically, and economically
situated. Rather than listing a hierarchy of principles,
where independent autonomy is privileged [47], this ap-
proach holds competing ethical issues in tension towards
the interdependent aim of the public's health, while rec-
ognizing that persons are not all equally situated in rela-
tion to opportunities for health [42]. Thus, recognizing
the many ways in which persons can be differentially
constrained based on different social locations. The PH
practitioner's task is to make visible the impacts that re-
sult from policy and healthcare decisions with a view to
equitably balancing competing demands amongst differ-
ently situated social groups.
However, to develop normative guidance for PH, it is
critical to ground ethical theory and perspectives in the
everyday ethical concerns that arise for practitioners
Applied ethicists Leget, Borry and DeVries [49]
argue that a critical ethical approach integrating empir-
ical research and normative ethical theory can clarify is-
sues and has the potential to set the conditions for
supporting real world practice through an ongoing dia-
lectical process. Thus, there is a role for research in
shaping the development of ethical frameworks
Page 4 of 11
be the level of where we sit with health equity and
they don't know how to talk about or they don't
publicly talk about what health has to say about the
the systemic stuff that we have, our policies that
create health inequity. (S4-02)
While participants recognized that the health system
was not solely responsible for addressing the determi-
nants of health, the lack of value for the PH role and fo-
cusing upstream on the root causes of health inequities
were often described by participants as unimportant to
health systems. This same participant describes the daily
ethical challenges of working in health care organiza-
tions that do not embrace health equity:
We're ethically challenged every day because we
work in health care in a place where people don't
have adequate services, don't get treated well in the
system, don't have proper housing. So, sort of a dif
ferent level for me. I was just going to say.... once
you start seeing the world through a social determi-
nants lens, it's like you're- you can never go back
and it's a bit of a curse. It's not easy. (S4-02)
Other participants also shared that once you saw the
world through a health equity lens it raised more ethical
challenges than if you did not, because it means living
with the moral discomfort of knowing what is needed
but being unable to act. They acknowledged that some-
mes it was easier for them and their colleagues not to
hold a health equity lens because accepting the status
quo reduces discomfort. This paradoxical "health equity
curse" included knowing that clients, families, groups,
communities and populations are experiencing deficits
in resources for health but their needs do not fit into the
dominant model of biomedical care.
This lack of access to resources for health was a fun-
damental ethical issue and experienced as morally dis-
tressing, as described by the following participant:
Because you know, you're stuck you can't give
people a better house......You can't get them a sink,
you can't give them the basic needs, right? So you
are, you're very torn and almost feel guilty at the
end of the day when you go home and you think, like
"God," you know? You stand in question of what you
have and what you need, and what people need in
society. (S4-20)
Working within a healthcare system that fails to act on
the determinants of health weighed heavily on the PH
practitioners in our study. They felt that they had few, if
any, resources available to address determinants of
health or the structural causes that produced health.
![inequities or the subsequent distress associated with be-
ing aware and unable to act.
Theme 2: procedures, checklists and checkboxes: systems
driven agendas versus situational care
Participants highlighted how the pressure of meeting
systems requirements drove PH work rather than the
situational needs of clients. Participants pointed to sys-
tems requirements such as procedures, guidelines,
checklists and checkboxes as the drivers of their work
and ultimately actions/inactions taken to promote health
equity. One participant described:
You know, public health is so indoctrinated with pol-
icies and procedures and guidelines and charting
and again, that often gets taken up with, you know,
what's being delivered from above into how we do
our work, So again, it's not really about the clients
themselves and the work with them, but it's about
the criteria put out by [Health Authority]. (S4-12)
In particular, PH practitioners described how systems
requirements, based on standardized assessments rather
than structural or situational factors were prioritized
when it came to determining eligibility for services and
programs. One participant stated:
Certain mothers quote unquote "qualify for a home
visit due to some varying risk factors. And is that an
equitable way of treating our population? Because it
leaves out that aesthetic way of knowing about that
person. You know? Saying "I just have this feeling
that this mom needs a visit" or "just from her tone of
voice, I think she's not telling me she's depressed but
I sense something" so I go out and visit and sure
enough, there's several different things going on. (S4-
18)
In addition to program eligibility criteria that allowed lit-
tle room for clinical assessment of situations, partici-
pants described the ethical issues of working with
checklists/checkboxes, procedures, and guidelines rather
than focusing on the person and their context.
So what I mean by that is probably in office if
we were to do ideal nursing work or ideal support,
family support work, we would be able to call all the
moms and ask them what they wanted from us and
be able to implement that whether it's going out to
see them in their homes, or taking them to, you
know, the store to buy proper food, you know, helping
them, whatever they wanted, whatever they felt that
they needed at that time to meet where they were at
If we were able to do that without constraints of
Pauly et al BMC Public Health (2021) 21:1567
stigmatize them sort of there, or don't look at all the
complexities that go into why that group, you know,
is more vulnerable. (S4-02)
For these practitioners, discussion was stifled leaving
sources of inequity unaddressed and continuing to oper-
ate in the very systems meant to provide care.
Theme 4: trust and autonomy versus surveillance and
social control
The context of relationships between practitioners and
clients was one of mistrust due to systemic stigma and
past negative experiences in healthcare. Consequently,
participants indicated that building and preserving trust.
and autonomy were priorities that sometimes came into
conflict with organizational legislated demands that
required measures of surveillance and at times social
control.
Participants particularly noted concerns related to
trust and autonomy around maintaining confidentiality
and consent regarding communicable disease reporting
to protect the public. Participants shared how navigating
STI reporting requires a nuanced approach to keep cli-
ents engaged in care and meet population health man-
dates. It takes time to build trust, learn details and assess
risks in a situation as well as decision making about how
to reduce both individual and population risks. One
practitioner described working with a client who was
positive for HIV and she had not told her partner.
Only a few hours ago we were faced with this ethical
issue where one of our clients who comes up from
time to time, where we know that she has an ongoing
relationship with someone who isn't aware of her
HIV status. And so that's always a bit of an issue....
but they aren't sexually active, so it hasn't been a
big concern to us that he doesn't know. But he said
that yesterday he was picking her up and then he
was poked with a needle. And so suddenly I'm think-
ing he needs to know so he can access care, he should
be offered post exposure prophylaxis and the window
is so short for that. But we can't inform him and
break her confidentiality. I wonder if we can find her
to talk to her and let her know, like "hey this is what
he told us. Can we work with you at all to disclose?"
... So I was sort of sitting here thinking "I can't not
do anything"... And I think really feeling the pres-
sure of it because of it being this short time frame
where we if we can get anything happening, we need
to get it happening now. (S4-23)
This exemplified how practitioners work to preserve
trust as well as being finely attuned to their clients and
their clients particular situations as they worked to
resources and um checklists and things like that......
...So I think for us, all our ethical dilemmas come
from the facts that we work on the ground very dif
ferently than what the people who create our re-
source pool and our jobs, and our job description
work from. (S4-04).
The examples above also highlight a move away from
universal to targeted programs with a focus on standard-
ized criteria for assessing risk. One participant describes
the evolution of this shift.
You know there's always a nurse available that if a
parent had been discharged with a new baby, they
would get a home visit to make sure that things are
going well, you know, to do an assessment on their
mood. So the universal program over the last num-
ber of years is getting more streamlined into more
targeted populations, the higher risk group or the
higher priorities is how they term it in public health.
So that, the universal approach, is kind of shifting a
bit, looking at budgets, you know, how to invest your
money, right? But always I feel that with the thought
of universal approach, a lot of people get kind of lost
- because it's not always obvious that there's issues,
right? (S4-12)
Systems requirements related to program eligibility, pro-
cedures, checklists and checkboxes and shift from uni-
versal to targeted programs shift the focus away from
promoting equity in that resources cannot be based on
assessment of need. Some practitioners pointed to the
mantra of patient centered care as a health system prior-
ity but with little attention to the social conditions that
impact individual health reflecting a value of individual-
ism/ neo-liberalism. Thus, there is a tension between
systems driven agendas in which the focus is on meeting
the demands/needs of the system and situationally
driven care in which individuals and their needs are
understood within a set of social circumstances.
Theme 3: systemic stigma and discrimination versus
respect for persons
Participants described stigma and discrimination as per-
vasive within health care systems. They described wit-
nessing various forms of stigma related to mental illness,
substance use, addiction, HIV, blaming and criminalizing
of people experiencing health inequities.
I find there's more judgement. You know not hav
ing the same kind of emphasis or compassion, or un-
derstanding of the complexities of health inequities,
you know, and the determinants of health, even
though that is part of the lens in public health,
Page 7 of 11
navigate their obligations in the face of possible risk to
the public. As our participants described, approaching
disclosure in a client led way was emotionally intense
and required persistent engagement, and ongoing assess-
ment. Acting prematurely might cause the client to dis-
engage and lose trust in the practitioner and then
increasing risks for population health. Thus, knowing
when it was appropriate to break confidentiality to dis-
close private information was a delicate relational dance
in which the practitioner had to balance the relationship
with client and the health of others as circumstances un-
folded. Although a different form of surveillance, the
practitioner below describes being requested to check up
on a client.
And the times where I feel like my ethics have been
compromised is where I've been asked to have quite
a specific follow up. Like, you know, one example
would be to call the doctor to make sure that the cli-
ent attended for a baby checkup. Or something like
that. For me, if that was an agreement I had with
the client already personally, I would feel okay about
that. But for me as maybe we've never even met, that
feels like policing and that feels unethical to me.
(S4-21)
This participant highlights that being asked to check on
someone s a form of policing in healthcare that feels
unethical. Other participants described ethically challen-
ging situations as knowing when to call the police or
child protection, knowing that such calls would bring in
systems of social control and work against the hard-
fought earning of trust. Participants described being in
the position of working to preserve and autonomy
with their clients and attempting to manage surveillance
and social control to prevent further inequities. We
would note that a focus on managing surveillance and
control takes the emphasis away from providing support
and access to resources that can promote health equity.
Strengths and limitations
There are several limitations of this analysis. First, it spe-
cifically focused on issues experienced by PH practi-
tioners in promoting mental health and preventing the
harms of substance use at a specific point in time. Eth-
ical issues may be different in other PH core program
areas. Yet, this may be an area of PH work where a lack
of attention to social determinants health (SDOH)
was more readily visible and apparent but at the same
time may not reflect health systems programs to connect
people to the SDOH or programs within health author-
ities that address issues related to SDOH like housing.
Second, this study took place in one provincial geo-
graphic context in Canada, representing rural to urban
there's still sort of ... there's a certain attitude of like
they choose just for themselves. (S4-12)
The quote above highlights a dominant understanding
that it is the individual who is to blame (e.g. they choose
this for themselves) rather than a recognition of systemic
inequities. The participant below describes how this
plays out specifically related to mental health and sub-
stance use.
Oh we won't treat you if you're using and if you're
mentally ill ... maybe it's because of your use, so
therefore we won't deal with you, I think that really
reflects our society's attitudes, about, probably our
state- about how we feel about mental health and
how we feel about addiction, right? So if you're so...
I don't know, you know, 'lazy', or 'unorganized' or
undisciplined enough' to be using something, we're
not so this is an underlying theme with addiction:
you know, you're not you're just a drain on our sys-
tem and so, you know, you're wasting bed space here
because you're addicted to something... So we want
you to get it together before you come back... So
there's that serious underlying theme that threads
through how, I think, our society sees people who use
drugs. And then, you know, so if they come in using
and with mental health, that kind of gets layered
into how they're treated. (S4-02)
While participants recognized stigma of mental health.
and substance use as in the example above, they were
less likely to name intersections of stigma with various
other forms of discrimination related to ethnicity, sex
and gender.
You know, there's certain gaps for instance for the
First Nations population who don't live on reserve,
they can access our services, right? But, you know,
there's just always, maybe not as comfortable to
walk into our building that's very clinical and very
institutional feeling - it's a very old building. You
know, big counter, so I mean I think that can be a
barrier for people feeling comfortable access the
services. (S4-12)
Although this PH practitioner did not directly
name racism or link the 'institutional feeling' to a
colonizing history, racial discrimination com-
pounds other stigma related to mental health and
substance use. Participants did at times identify
sex and gender as areas of discrimination but did
not necessarily recognize or identify the intersec-
tions of various forms of stigma
discrimination.
Pauly et al BMC Public Health (2021) 21:1567
settings with different systems of health care delivery
across six different publicly funded Health Authorities.
Reporting to the provincial Ministry of Health, each
Health Authority delivers the same public health services
but tailored to their context. However, this may also be
a strength and contribute to the opportunity to extend
these findings to other contexts.
Discussion
In this paper, we have sketched out systemic ethical
challenges in PH practice related to the promotion of
health equity. We specifically outline four systemic eth-
ical challenges that arise in PH practice related to the
dominance of biomedicine, bureaucratic systems, sys-
temic stigma and discrimination, and potential systems
of surveillance and control. All of these shape PH pro-
viders' interactions with clients and affect their ability to
promote health equity. The dominance of biomedicine
in the health care system focuses action on treatment of
disease for individuals leaving little space for public
health and little attention to the broader social determi-
nants of health or more simply the conditions in which
people live and work. Systems requirements, often in-
fused with the values of biomedicine and individualism
(such as procedures and standardized checklists) do not
account for the unique situatedness in which individuals,
groups and communities are positioned. In the current
health care system dominated by biomedicine and bur
eaucratic approaches to care and the presence of stigma,
it is often difficult and challenging for PH providers to
meet obligations related to health equity leaving them
with the burden of unmet needs and feeling like health
equity is a curse. This study provides insights into health
equity issues in public health that are only briefly men-
tioned in others studies of public health ethics issues
noted at the beginning of this paper.
Notable in the ethical concerns of PH providers is the
pull of biomedicine, neo-liberal and individualist dis-
courses that obscure the broader social and often struc-
turally violent conditions that produce vulnerability to
health inequities. Similarly, in a systematic review of lit-
erature on health equity, Farrar and colleagues [61] iden-
tified that capitalism, biomedicine and difficulties with
collaboration impact the ability of public health to advo-
cate for health. In fact, Smith [53] found that PH deci-
sion makers were uncomfortable and shied away from
issues related to justice and power. Participants de-
scribed having to practice within health systems that
drift to targeting behaviors of individuals, groups, and
populations rather than recognizing social, economic,
historical, and political risks, and social conditions that
impact health. Despite the growing evidence that tar-
geted behavioral approaches have limited utility for
groups experiencing disadvantage [62, 63] are ineffective
As a result of various forms of stigma and discrimin-
ation, participants described healthcare systems as pro-
ducing mistrust and affecting health care experiences of
populations they were working with.
And because they've probably been treated in the
past, they're not wanting to access service and they
mistrust now....The majority of my clientele that
work with will not, and I've never seen this before,
will not go to the hospital. And I kid you not, until
it's almost too late or too late. I've never seen that,
because of how they've been treated. (S4-25)
Participants described how their clients' concerns were
often dismissed outright and the challenges related to
system processes such as navigating through bureau-
cracy, filling out multiple forms and getting through
gatekeepers was daunting, creating ethical concerns re-
lated to the personal capacity and energy of clients and
practitioners to work to access a system that is highly
stigmatizing and limited in what can be provided. For
example, one participant described the work of carefully
choosing terminology in documentation to favorably
present a client so that they could get access to housing
and described this as 'fudging it" rather than seeing this
as a way to reduce stigma knowing that housing was
scarce commodity in the community.
Several participants discussed how the line between
practitioner and client experiences is not so distinct.
Some participants self-identified as having past problem-
atic drug use, being gender non-conforming, having ex-
perience with mental health issues, or having family
members or loved ones in need of mental health or sub-
stance use supports. One participant described how their
identity as queer was not recognized as an asset in the
workplace but rather something that they had to manage
carefully in terms of who they shared this information
with. Finally, because the work of PH practitioners
brought them close to groups that are so often stigma-
tized, they were found themselves personally impacted
by stigma, "I think the work that we do is also stigma-
tized. Like, our clients are stigmatized for their health
and social status and we are stigmatized for working
with them" (S4-20). Thus, having to navigate stigma and
discrimination on multiple fronts for themselves and
their clients. However, there was seemingly little appetite.
to address systemic stigma within organizations.
My agency they say they care about these issues
[of equity], but if we start talking about them too
much, they tell us to not talk openly about it. Yeah.
Like a few of us will get quite fired up every so often
about they profile groups, and then, you know,
say "These people are more at risk and they
Page 8 of 11
[64] and may, in some cases, even widen inequities [65],
lifestyle and behavioral approaches still dominate within
Canadian PH policy [21, 64]. In fact, much of what par-
ticipants are calling for here relation to assessing and
providing resources based on need is aligned with pro-
portionate universalism, an approach where health ac-
tions are universal but provided in proportionate to level
of disadvantage [66].
Stigma related to illicit substance use, homelessness,
mental illness, HIV, Hepatitis C, often intersect with
forms of discrimination including racism, classism, and
gender bias [8]. These findings broaden the understand-
ing of stigma as an ethical issue in healthcare beyond as-
sociation with disease conditions to encompass poverty
and substance use stigma [67]. Stigma and discrimin-
ation contribute to social exclusion, limit access to re-
sources for health and exacerbate health inequities. It is
clear from our findings that stigma is pervasive in
healthcare reflecting unjust structural arrangements lim-
iting the achievement of health equity. Of note, partici-
pants often spoke to one but not multiples sources of
stigma. It is not clear whether this is due to the com-
plexity of multiples stigmas and discrimination and/or
lack of knowledge about how various forms of stigma
and discrimination compound creating even greater in-
equities for some. Furthermore, it is of serious concern
that participants felt that their attempts to address sys-
temic stigma within healthcare are stifled and that they
experience stigma by association, also known as courtesy
stigma [68, 69].
All PH practitioners in our study described the nega-
tive effects of seeing firsthand or hearing stories from
their clients about the challenge of living with health in-
equities. They bore witness to the interface of clients
with the healthcare system and the inability of such sys-
tems to address health inequities. Thus, what became
clear is that PH practitioners' call to act is not an ab-
straction but comes from their professional obligations
and from working with, alongside, and in communities
experiencing health and social inequities. Much has been
written about moral distress in acute care with less at-
tention to moral distress among PH practitioners [70-
72]. What is strikingly similar is the degree to which PH
practitioners are bearing witness to systemic issues over
which they have little control (e.g. structural conditions)
and as a result feel powerless to assist
when health equity is articulated as important and ex-
pected [25].
clients even
Reducing health inequities must include actions that:
[1] improve the conditions of daily life; [2] tackle the in-
equitable distribution of power, money and resources;
and [3] measure and understand the problem and assess
the impact of action (Commission on the Social Deter-
minants of Health, 2008). As Jennings [46] observes,](/v2/_next/image?url=https%3A%2F%2Fcontent.bartleby.com%2Fqna-images%2Fquestion%2Fac3be618-b645-4bd8-855b-808ff3fc18d4%2F7b3976be-cdf7-4d0b-819e-3ca1af5d0f03%2Fzeosfac_processed.png&w=3840&q=75)
Transcribed Image Text:inequities or the subsequent distress associated with be-
ing aware and unable to act.
Theme 2: procedures, checklists and checkboxes: systems
driven agendas versus situational care
Participants highlighted how the pressure of meeting
systems requirements drove PH work rather than the
situational needs of clients. Participants pointed to sys-
tems requirements such as procedures, guidelines,
checklists and checkboxes as the drivers of their work
and ultimately actions/inactions taken to promote health
equity. One participant described:
You know, public health is so indoctrinated with pol-
icies and procedures and guidelines and charting
and again, that often gets taken up with, you know,
what's being delivered from above into how we do
our work, So again, it's not really about the clients
themselves and the work with them, but it's about
the criteria put out by [Health Authority]. (S4-12)
In particular, PH practitioners described how systems
requirements, based on standardized assessments rather
than structural or situational factors were prioritized
when it came to determining eligibility for services and
programs. One participant stated:
Certain mothers quote unquote "qualify for a home
visit due to some varying risk factors. And is that an
equitable way of treating our population? Because it
leaves out that aesthetic way of knowing about that
person. You know? Saying "I just have this feeling
that this mom needs a visit" or "just from her tone of
voice, I think she's not telling me she's depressed but
I sense something" so I go out and visit and sure
enough, there's several different things going on. (S4-
18)
In addition to program eligibility criteria that allowed lit-
tle room for clinical assessment of situations, partici-
pants described the ethical issues of working with
checklists/checkboxes, procedures, and guidelines rather
than focusing on the person and their context.
So what I mean by that is probably in office if
we were to do ideal nursing work or ideal support,
family support work, we would be able to call all the
moms and ask them what they wanted from us and
be able to implement that whether it's going out to
see them in their homes, or taking them to, you
know, the store to buy proper food, you know, helping
them, whatever they wanted, whatever they felt that
they needed at that time to meet where they were at
If we were able to do that without constraints of
Pauly et al BMC Public Health (2021) 21:1567
stigmatize them sort of there, or don't look at all the
complexities that go into why that group, you know,
is more vulnerable. (S4-02)
For these practitioners, discussion was stifled leaving
sources of inequity unaddressed and continuing to oper-
ate in the very systems meant to provide care.
Theme 4: trust and autonomy versus surveillance and
social control
The context of relationships between practitioners and
clients was one of mistrust due to systemic stigma and
past negative experiences in healthcare. Consequently,
participants indicated that building and preserving trust.
and autonomy were priorities that sometimes came into
conflict with organizational legislated demands that
required measures of surveillance and at times social
control.
Participants particularly noted concerns related to
trust and autonomy around maintaining confidentiality
and consent regarding communicable disease reporting
to protect the public. Participants shared how navigating
STI reporting requires a nuanced approach to keep cli-
ents engaged in care and meet population health man-
dates. It takes time to build trust, learn details and assess
risks in a situation as well as decision making about how
to reduce both individual and population risks. One
practitioner described working with a client who was
positive for HIV and she had not told her partner.
Only a few hours ago we were faced with this ethical
issue where one of our clients who comes up from
time to time, where we know that she has an ongoing
relationship with someone who isn't aware of her
HIV status. And so that's always a bit of an issue....
but they aren't sexually active, so it hasn't been a
big concern to us that he doesn't know. But he said
that yesterday he was picking her up and then he
was poked with a needle. And so suddenly I'm think-
ing he needs to know so he can access care, he should
be offered post exposure prophylaxis and the window
is so short for that. But we can't inform him and
break her confidentiality. I wonder if we can find her
to talk to her and let her know, like "hey this is what
he told us. Can we work with you at all to disclose?"
... So I was sort of sitting here thinking "I can't not
do anything"... And I think really feeling the pres-
sure of it because of it being this short time frame
where we if we can get anything happening, we need
to get it happening now. (S4-23)
This exemplified how practitioners work to preserve
trust as well as being finely attuned to their clients and
their clients particular situations as they worked to
resources and um checklists and things like that......
...So I think for us, all our ethical dilemmas come
from the facts that we work on the ground very dif
ferently than what the people who create our re-
source pool and our jobs, and our job description
work from. (S4-04).
The examples above also highlight a move away from
universal to targeted programs with a focus on standard-
ized criteria for assessing risk. One participant describes
the evolution of this shift.
You know there's always a nurse available that if a
parent had been discharged with a new baby, they
would get a home visit to make sure that things are
going well, you know, to do an assessment on their
mood. So the universal program over the last num-
ber of years is getting more streamlined into more
targeted populations, the higher risk group or the
higher priorities is how they term it in public health.
So that, the universal approach, is kind of shifting a
bit, looking at budgets, you know, how to invest your
money, right? But always I feel that with the thought
of universal approach, a lot of people get kind of lost
- because it's not always obvious that there's issues,
right? (S4-12)
Systems requirements related to program eligibility, pro-
cedures, checklists and checkboxes and shift from uni-
versal to targeted programs shift the focus away from
promoting equity in that resources cannot be based on
assessment of need. Some practitioners pointed to the
mantra of patient centered care as a health system prior-
ity but with little attention to the social conditions that
impact individual health reflecting a value of individual-
ism/ neo-liberalism. Thus, there is a tension between
systems driven agendas in which the focus is on meeting
the demands/needs of the system and situationally
driven care in which individuals and their needs are
understood within a set of social circumstances.
Theme 3: systemic stigma and discrimination versus
respect for persons
Participants described stigma and discrimination as per-
vasive within health care systems. They described wit-
nessing various forms of stigma related to mental illness,
substance use, addiction, HIV, blaming and criminalizing
of people experiencing health inequities.
I find there's more judgement. You know not hav
ing the same kind of emphasis or compassion, or un-
derstanding of the complexities of health inequities,
you know, and the determinants of health, even
though that is part of the lens in public health,
Page 7 of 11
navigate their obligations in the face of possible risk to
the public. As our participants described, approaching
disclosure in a client led way was emotionally intense
and required persistent engagement, and ongoing assess-
ment. Acting prematurely might cause the client to dis-
engage and lose trust in the practitioner and then
increasing risks for population health. Thus, knowing
when it was appropriate to break confidentiality to dis-
close private information was a delicate relational dance
in which the practitioner had to balance the relationship
with client and the health of others as circumstances un-
folded. Although a different form of surveillance, the
practitioner below describes being requested to check up
on a client.
And the times where I feel like my ethics have been
compromised is where I've been asked to have quite
a specific follow up. Like, you know, one example
would be to call the doctor to make sure that the cli-
ent attended for a baby checkup. Or something like
that. For me, if that was an agreement I had with
the client already personally, I would feel okay about
that. But for me as maybe we've never even met, that
feels like policing and that feels unethical to me.
(S4-21)
This participant highlights that being asked to check on
someone s a form of policing in healthcare that feels
unethical. Other participants described ethically challen-
ging situations as knowing when to call the police or
child protection, knowing that such calls would bring in
systems of social control and work against the hard-
fought earning of trust. Participants described being in
the position of working to preserve and autonomy
with their clients and attempting to manage surveillance
and social control to prevent further inequities. We
would note that a focus on managing surveillance and
control takes the emphasis away from providing support
and access to resources that can promote health equity.
Strengths and limitations
There are several limitations of this analysis. First, it spe-
cifically focused on issues experienced by PH practi-
tioners in promoting mental health and preventing the
harms of substance use at a specific point in time. Eth-
ical issues may be different in other PH core program
areas. Yet, this may be an area of PH work where a lack
of attention to social determinants health (SDOH)
was more readily visible and apparent but at the same
time may not reflect health systems programs to connect
people to the SDOH or programs within health author-
ities that address issues related to SDOH like housing.
Second, this study took place in one provincial geo-
graphic context in Canada, representing rural to urban
there's still sort of ... there's a certain attitude of like
they choose just for themselves. (S4-12)
The quote above highlights a dominant understanding
that it is the individual who is to blame (e.g. they choose
this for themselves) rather than a recognition of systemic
inequities. The participant below describes how this
plays out specifically related to mental health and sub-
stance use.
Oh we won't treat you if you're using and if you're
mentally ill ... maybe it's because of your use, so
therefore we won't deal with you, I think that really
reflects our society's attitudes, about, probably our
state- about how we feel about mental health and
how we feel about addiction, right? So if you're so...
I don't know, you know, 'lazy', or 'unorganized' or
undisciplined enough' to be using something, we're
not so this is an underlying theme with addiction:
you know, you're not you're just a drain on our sys-
tem and so, you know, you're wasting bed space here
because you're addicted to something... So we want
you to get it together before you come back... So
there's that serious underlying theme that threads
through how, I think, our society sees people who use
drugs. And then, you know, so if they come in using
and with mental health, that kind of gets layered
into how they're treated. (S4-02)
While participants recognized stigma of mental health.
and substance use as in the example above, they were
less likely to name intersections of stigma with various
other forms of discrimination related to ethnicity, sex
and gender.
You know, there's certain gaps for instance for the
First Nations population who don't live on reserve,
they can access our services, right? But, you know,
there's just always, maybe not as comfortable to
walk into our building that's very clinical and very
institutional feeling - it's a very old building. You
know, big counter, so I mean I think that can be a
barrier for people feeling comfortable access the
services. (S4-12)
Although this PH practitioner did not directly
name racism or link the 'institutional feeling' to a
colonizing history, racial discrimination com-
pounds other stigma related to mental health and
substance use. Participants did at times identify
sex and gender as areas of discrimination but did
not necessarily recognize or identify the intersec-
tions of various forms of stigma
discrimination.
Pauly et al BMC Public Health (2021) 21:1567
settings with different systems of health care delivery
across six different publicly funded Health Authorities.
Reporting to the provincial Ministry of Health, each
Health Authority delivers the same public health services
but tailored to their context. However, this may also be
a strength and contribute to the opportunity to extend
these findings to other contexts.
Discussion
In this paper, we have sketched out systemic ethical
challenges in PH practice related to the promotion of
health equity. We specifically outline four systemic eth-
ical challenges that arise in PH practice related to the
dominance of biomedicine, bureaucratic systems, sys-
temic stigma and discrimination, and potential systems
of surveillance and control. All of these shape PH pro-
viders' interactions with clients and affect their ability to
promote health equity. The dominance of biomedicine
in the health care system focuses action on treatment of
disease for individuals leaving little space for public
health and little attention to the broader social determi-
nants of health or more simply the conditions in which
people live and work. Systems requirements, often in-
fused with the values of biomedicine and individualism
(such as procedures and standardized checklists) do not
account for the unique situatedness in which individuals,
groups and communities are positioned. In the current
health care system dominated by biomedicine and bur
eaucratic approaches to care and the presence of stigma,
it is often difficult and challenging for PH providers to
meet obligations related to health equity leaving them
with the burden of unmet needs and feeling like health
equity is a curse. This study provides insights into health
equity issues in public health that are only briefly men-
tioned in others studies of public health ethics issues
noted at the beginning of this paper.
Notable in the ethical concerns of PH providers is the
pull of biomedicine, neo-liberal and individualist dis-
courses that obscure the broader social and often struc-
turally violent conditions that produce vulnerability to
health inequities. Similarly, in a systematic review of lit-
erature on health equity, Farrar and colleagues [61] iden-
tified that capitalism, biomedicine and difficulties with
collaboration impact the ability of public health to advo-
cate for health. In fact, Smith [53] found that PH deci-
sion makers were uncomfortable and shied away from
issues related to justice and power. Participants de-
scribed having to practice within health systems that
drift to targeting behaviors of individuals, groups, and
populations rather than recognizing social, economic,
historical, and political risks, and social conditions that
impact health. Despite the growing evidence that tar-
geted behavioral approaches have limited utility for
groups experiencing disadvantage [62, 63] are ineffective
As a result of various forms of stigma and discrimin-
ation, participants described healthcare systems as pro-
ducing mistrust and affecting health care experiences of
populations they were working with.
And because they've probably been treated in the
past, they're not wanting to access service and they
mistrust now....The majority of my clientele that
work with will not, and I've never seen this before,
will not go to the hospital. And I kid you not, until
it's almost too late or too late. I've never seen that,
because of how they've been treated. (S4-25)
Participants described how their clients' concerns were
often dismissed outright and the challenges related to
system processes such as navigating through bureau-
cracy, filling out multiple forms and getting through
gatekeepers was daunting, creating ethical concerns re-
lated to the personal capacity and energy of clients and
practitioners to work to access a system that is highly
stigmatizing and limited in what can be provided. For
example, one participant described the work of carefully
choosing terminology in documentation to favorably
present a client so that they could get access to housing
and described this as 'fudging it" rather than seeing this
as a way to reduce stigma knowing that housing was
scarce commodity in the community.
Several participants discussed how the line between
practitioner and client experiences is not so distinct.
Some participants self-identified as having past problem-
atic drug use, being gender non-conforming, having ex-
perience with mental health issues, or having family
members or loved ones in need of mental health or sub-
stance use supports. One participant described how their
identity as queer was not recognized as an asset in the
workplace but rather something that they had to manage
carefully in terms of who they shared this information
with. Finally, because the work of PH practitioners
brought them close to groups that are so often stigma-
tized, they were found themselves personally impacted
by stigma, "I think the work that we do is also stigma-
tized. Like, our clients are stigmatized for their health
and social status and we are stigmatized for working
with them" (S4-20). Thus, having to navigate stigma and
discrimination on multiple fronts for themselves and
their clients. However, there was seemingly little appetite.
to address systemic stigma within organizations.
My agency they say they care about these issues
[of equity], but if we start talking about them too
much, they tell us to not talk openly about it. Yeah.
Like a few of us will get quite fired up every so often
about they profile groups, and then, you know,
say "These people are more at risk and they
Page 8 of 11
[64] and may, in some cases, even widen inequities [65],
lifestyle and behavioral approaches still dominate within
Canadian PH policy [21, 64]. In fact, much of what par-
ticipants are calling for here relation to assessing and
providing resources based on need is aligned with pro-
portionate universalism, an approach where health ac-
tions are universal but provided in proportionate to level
of disadvantage [66].
Stigma related to illicit substance use, homelessness,
mental illness, HIV, Hepatitis C, often intersect with
forms of discrimination including racism, classism, and
gender bias [8]. These findings broaden the understand-
ing of stigma as an ethical issue in healthcare beyond as-
sociation with disease conditions to encompass poverty
and substance use stigma [67]. Stigma and discrimin-
ation contribute to social exclusion, limit access to re-
sources for health and exacerbate health inequities. It is
clear from our findings that stigma is pervasive in
healthcare reflecting unjust structural arrangements lim-
iting the achievement of health equity. Of note, partici-
pants often spoke to one but not multiples sources of
stigma. It is not clear whether this is due to the com-
plexity of multiples stigmas and discrimination and/or
lack of knowledge about how various forms of stigma
and discrimination compound creating even greater in-
equities for some. Furthermore, it is of serious concern
that participants felt that their attempts to address sys-
temic stigma within healthcare are stifled and that they
experience stigma by association, also known as courtesy
stigma [68, 69].
All PH practitioners in our study described the nega-
tive effects of seeing firsthand or hearing stories from
their clients about the challenge of living with health in-
equities. They bore witness to the interface of clients
with the healthcare system and the inability of such sys-
tems to address health inequities. Thus, what became
clear is that PH practitioners' call to act is not an ab-
straction but comes from their professional obligations
and from working with, alongside, and in communities
experiencing health and social inequities. Much has been
written about moral distress in acute care with less at-
tention to moral distress among PH practitioners [70-
72]. What is strikingly similar is the degree to which PH
practitioners are bearing witness to systemic issues over
which they have little control (e.g. structural conditions)
and as a result feel powerless to assist
when health equity is articulated as important and ex-
pected [25].
clients even
Reducing health inequities must include actions that:
[1] improve the conditions of daily life; [2] tackle the in-
equitable distribution of power, money and resources;
and [3] measure and understand the problem and assess
the impact of action (Commission on the Social Deter-
minants of Health, 2008). As Jennings [46] observes,
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