Violence and Public Health Ethics
Abstract and Keywords
This chapter discusses the ethical issues and impact of interpersonal and self-directed violence on the health of the global population. Interpersonal and self-directed violence (self-harm) are leading causes of death and disability globally, and international guidelines recommend provision of services to those affected by violence, research into the prevalence of violence, and advocacy and training to prevent violence. Importantly, public health practice and research on violence present both global and context-specific ethical challenges. This chapter describes the impact of violence on public health, the role of public health practitioners in addressing violence, fundamental ethical principles and guidelines for public health workers to address violence, and ethical challenges for research and programs dealing with violence, including fair approaches to violence screening and response, safe means of collecting data about violence, reducing risks when resources are limited, and autonomy versus paternalism in suicide management. The chapter concludes by suggesting strategies for the ethical practice of public health in the context of violence.
(p. 617) Understanding Violence through a Public Health Lens
The World Health Organization (WHO) has defined violence as the “intentional use of physical force or power . . . that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation” (WHO, 2002). The WHO has developed a typology of violence based on the victim-perpetrator relationship: self-directed violence, interpersonal violence, and collective violence, represented in Figure 53.1.
This chapter builds on previous work (Kass, 2004; Thomas et al., 2002) and focuses on the ethics of public health practice as related to self-directed and interpersonal violence. Self-directed violence encompasses a range of behaviors, including acts of fatal and nonfatal suicidal behavior, as well as behaviors for which the intention is not to kill oneself but rather to harm, as in self-mutilation. Suicidal ideation (i.e., thinking about, considering, or planning for suicide) is often included in this definition because of its association with self-directed violence (Crosby, Ortega, and Melanson, 2011). Interpersonal violence is further categorized by the relationship between the victim and perpetrator, who may be an intimate partner, family member, acquaintance, or stranger. It may also be characterized by the victim’s age or sex (e.g., violence against children, adolescents, women, and elderly persons), or by the nature of the violence (e.g., physical, sexual, psychological, or deprivation/neglect). By contrast, collective violence is defined as the instrumental use of violence by people identifying themselves as a group against another group to achieve political, economic, or social objectives. While the practice of public health within the context of collective violence is a pressing concern, it is beyond the scope of this chapter.
(p. 618) In this chapter, we first discuss the impact of violence on public health and the role of public health practitioners in addressing violence. We then review fundamental ethical principles and current guidelines for public health workers to address violence, and examine some ethical challenges for research and programs dealing with interpersonal and self-directed violence. We conclude by suggesting a way forward for the ethical practice of public health regarding violence.
The Impact of Violence on the Public’s Health
Rates of self-directed violence differ by geography, by demographic characteristics, and by individual vulnerability, including mental health status. An estimated 800,000 suicide deaths occur each year (Lozano et al., 2012). In 2015 suicide was one of the three leading causes of death globally among people aged fifteen to twenty-nine, and the seventeenth leading cause of death among all ages. Globally, the age-standardized rate of suicide death is 14 per 100,000, with the highest rates seen among people aged over seventy (29.3 per 100,000) and those between the ages of fifty and sixty-nine (18.5 per 100,000) (Lozano et al., 2012). Suicide attempts are twenty times more common than (p. 619) suicide fatality (WHO, 2014), and rates of nonsuicidal self-injury are even higher: 4–6 percent of people have deliberately self-injured at least once (Weber et al., 2013).
Interpersonal violence is the fourth-leading cause of death and leads to substantial disability among youth aged ten to twenty-nine, accounting for 200,000 deaths annually (WHO, 2014). Reliable global estimates of child maltreatment are scarce; however, one in four adults reports having been physically abused during childhood (Stoltenborgh et al., 2013). Physical and sexual violence against women is similarly pervasive, as one in three women reports being abused during her lifetime (WHO, 2013). Violence against elderly persons is increasingly recognized to be a problem, with estimates of one in six of people above sixty years of age experiencing some form of abuse (Yon et al., 2017).
Knowledge of the burden of violence, its risk factors, and effective interventions has increased exponentially. In many high-income countries, this increased knowledge has resulted in significant declines in violence-related mortality and morbidity. By contrast, in many low- and middle-income countries (LMICs), rates of violence are twice as high, and there is an imperative to rapidly advance a violence prevention agenda that recognizes the unique ethical challenges faced by LMICs, examples of which are discussed in this chapter.
Preventing and Responding to Violence: The Role of Public Health
According to the WHO Global Plan of Action (2016a), national health care systems should provide services to those affected by violence, gather data to assess the magnitude of the problem, provide and evaluate interventions, develop intersectoral links, and engage in advocacy and training to address and prevent violence (see Figure 53.2).
Provision of Health Care for Victims of Violence
National health systems have a key role to play in the multisectoral response to violence. They provide appropriate clinical care to address the outcomes of violence, treatment of physical injuries, and management of mental health effects seen in victims of violence (García-Moreno et al., 2015). There is a dearth of evidence of effective health care interventions for violence prevention, especially for resource-poor settings; however, there is a consensus that health care professionals should identify patients experiencing violence and provide supportive care as well as referral to other services (US Preventive Services Task Force, 2013). Health care systems can contribute to violence prevention or recurrence and mitigation of the consequences, in addition to urgent and ongoing care.
Examples of the roles that health care professionals play in managing violence and its impact include identifying cases where injuries are a result of violence (Concialdi and Read, 2016), assessment of individual risk of violence or preventive screening for violence (p. 620) (US Preventive Services Task Force, 2013), and gathering forensic evidence (ACEP, 2013). In the context of self-directed violence, for example, screening for suicide risk among populations assessed to be at high likelihood for suicide is also carried out by health care personnel (Walrath et al., 2015).
Development of Intersectoral Links
Intersectoral collaboration is necessary for the success of efforts to mitigate and prevent violence. The health system ought to work closely with social services, education systems, local communities, policymakers, and law enforcement in a collaborative and meaningful way to effectively address violence. National legislative mechanisms also play a critical role in violence prevention in any country (WHO, 2002).
At the most basic and individual level, this linkage involves referring victims of interpersonal violence by health care workers to protective services such as alternative living arrangements, social services, access to mental health care, and legal support if possible and desired by the individual (WHO, 2009), as well as appropriate collection and (p. 621) preservation of forensic evidence by health care personnel in cases of violence, particularly sexual violence (Foresman-Capuzzi, 2014). However, a more robust collaborative process is necessary to address violence at the population level. An example of this is the WHO Regional Office for Europe’s plan to reduce the prevalence of child maltreatment by implementing preventive programs that address risk and protective factors, including social determinants (WHO/Europe, 2014). Specifically, the plan calls for addressing the causes of maltreatment through coordinated and sustained efforts in multiple sectors (health, education, employment, welfare, justice, housing, trade and industry, media and communications, and nongovernmental organizations) as well as health systems.
In the context of suicide, the current link between health and other sectors, such as national legislatures and the community at large, centers on issues of access to adequate and consistent mental health care, perceived causes of suicide (i.e., underlying mental illness or social conditions), widespread social stigmatization, and most societies’ overarching desire to prevent suicide (Ho, 2014).
Surveillance and Evaluation
National public health authorities ought to conduct surveillance to collect accurate, timely, and comprehensive data to better understand and prevent the occurrence of violence. Monitoring the occurrence and nature of violent deaths and injuries, ensuring that data are disseminated routinely and expeditiously, and applying these data to develop, implement, and evaluate programs and strategies to reduce and prevent violence are all integral parts of an effective surveillance mechanism. An example of surveillance for violence is the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS), which gathers information across provinces and territories, each of which functions under its own legislation for child welfare. The CIS is the longest-standing national surveillance mechanism for violence against children, bringing together disparate reporting mechanisms and establishing standard definitions for types of child maltreatment (Tonmyr, 2015). Despite these strengths, this passive surveillance mechanism represents only those cases that are reported to child welfare agencies; therefore, there is likely underreporting of cases (Tonmyr et al., 2010).
Advocacy and Training
The global public health community has taken a lead in raising awareness of the impact of violence and has advanced the agenda of violence prevention through advocacy mechanisms focusing on international human rights treaties as well as civil and political rights, such as the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) (Schopper, Lormand, and Waxweiler, 2006). Other activities at this level include the development of technical guidelines, policy papers, and research (p. 622) to support violence prevention programs and advocate for increased investment in violence prevention (WHO, 2002).
At the country level, advocacy and capacity development spans legislative and policy standards, allocation of adequate resources, strengthening systems that prevent and respond to violence, and changing social and cultural norms that tolerate violence. The WHO Global Status Report on Violence Prevention 2014 outlines the status of violence prevention activities across the globe (Mikton et al., 2016). More than two-thirds of countries have national action plans to address child maltreatment and intimate partner or sexual violence; however, these plans are unlikely to be informed by data. Almost 60 percent of countries do not have reliable data on violence-related mortality, and even fewer have information specific enough to inform programming. Additionally, fewer than half of all countries report implementation of large-scale, evidence-based interventions for violence prevention. Even more concerning is the dearth of effective legislative recourse for victims of violence in many countries. Despite a growing evidential basis for addressing violence as a public health issue and widespread adoption of international commitments to violence prevention, countries need to do more to reduce the occurrence and impact of violence (Mikton et al., 2016). With this background in mind, we will now provide a summary of ethical principles used in the context of public health and public health response. We will then describe specific ethical challenges in the context of interpersonal violence, linking how these principles can provide some guidance for the challenges described.
Ethical Principles for Public Health
Beauchamp and Childress (2012) outline four ethical principles applicable to all of biomedicine: beneficence, nonmaleficence, respect for autonomy, and justice. Beneficence involves evaluating positive impacts of health actions and balancing the benefits against risks, whereas nonmaleficence means understanding, reducing, and avoiding any negative effects of interventions. Respect for autonomy requires respecting the rights of individuals and communities to determine their own course of action and support for independent decision-making. Justice is the ethical duty to promote and act with fairness. It generally includes both a distributive component (for example, the equitable distribution of resources for health, or distribution of the opportunity to be healthy) and a procedural component (having fair procedures in place to resolve disagreements or set priorities among competing demands).
Yet within public health, how the above four principles are specified, and which ethical demands are given priority, is important. Because public health seeks to maximize the health of entire populations as opposed to only individuals, public health ethics frameworks seek to assure that policies and programs that aim to improve the health of the public do so with minimal infringement to liberty and with privileged attention to justice (Childress et al., 2002). Public health ethics asks public health professionals to (p. 623) identify population-wide priorities for health, consider the effectiveness and benefits of programs or policies in achieving these public health priorities, maximize benefits over harms (utility), justify that the public health activities will minimize morbidity or mortality, pose the least infringement to autonomy rights as possible, and maintain privacy and confidentiality as well as public trust (Kass, 2001; Childress et al., 2002). In addition, particularly since public health outcomes are correlated with social justice and equity outcomes, attention to justice is a core commitment of public health. This requires ensuring that populations are not inadvertently targeted, that unjust conditions are rectified, and that, ultimately, procedural justice (participation of the public, local communities, and affected groups through transparency processes) is in place to resolve disagreements (Kass, 2001; Childress et al., 2002).
Ultimately, most areas of public health—including how best to design screening or vaccination programs; how to organize data collection, surveillance, or disease and injury reporting; how best to allocate scarce resources; and when to have more coercive and regulatory measures implemented in the name of improving the public’s health—raise ethics issues, and attention to effectiveness, least infringement, necessity, and fair distribution and procedures becomes essential. Indeed, the last decades have seen an increasing focus on ethical issues inherent in the practice of public health (Dawson, 2009, 2011; Peckham and Hann, 2010; Faden and Shebaya, 2016; Goldberg, 2017).
The next section highlights key ethics challenges, particularly in the area of interpersonal violence as a public health issue, including surveillance and data gathering related to violence, screening programs for violence, and public health interventions to address violence.
Ethical Challenges in Addressing Interpersonal Violence
Data suggest that the prevalence of violence is higher among those with lower incomes; nonetheless, it remains a critical public health problem for adults of all income levels (Breiding, Chen, and Black, 2014). Often, it is advocated that efforts to combat violence focus on low-income and minority groups (APA, 2009). While the rationale for such an approach is understandable, there is a risk of reinforcing classist, racist, and inaccurate presuppositions that individuals in these populations are uniquely predisposed to act violently (Greaves et al., 1995). In the United States, low-income, urban communities that are largely populated by minorities experience a greater law enforcement presence in response to violence, increasing the likelihood of police-involved violence with each encounter and perpetuating a cycle of violence (Obasogie and Newman, 2017). In LMICs, urban space is increasingly organized in response to crime and violence and to a lack of confidence in the state’s provision of security. This isolation perpetuates a fear of the “Other” and contributes to the social, economic, and political fragmentation (p. 624) of cities (Moser, 2004). In such contexts, violence cannot be viewed in isolation; it is necessary to understand these phenomena in their broader sociological context of inequality, deprivation, and insecurity (Kruijt, 2007).
Gathering Information for Surveillance, Evaluation, and Research to Address Violence
The collection, holding, and dissemination of data related to violence may pose risks to both those who report the information and those who collect it (Lee and Renzetti, 1990; Fontes, 2014). This necessitates maintaining high standards to ensure confidentiality in research studies and any other data collection related to violence. While there is little empirical evidence that participants in research on violence are at greater risk of harm than any other research participants (Sikweyiya and Jewkes, 2011), the potential risk of individual harm, risks to those involved in gathering data, and a broader concern of risks to a community or identity are all important considerations. Concerns about confidentiality emerge not only from breaches of confidentiality of data already collected, but also from how data gathering activities are conducted (WHO, 2001). Further, there can be risks associated with having names on a list or registry of those impacted by violence.
An example of the latter from an LMIC context is the Hudood Ordinances that became part of Pakistan’s penal code in 1979, enforcing severe punishments for adultery. In combination with Pakistan’s 1984 Law of Evidence, the law requires four Muslim men of good character to come forward as witnesses to verify a woman’s claim of rape. In cases where there are no witnesses, police reports of rape are treated as a confession of adultery, and the victims have been subject to punishment (Rathore, 2015). In such a setting, the identification of sexually abused women by public health programs is especially dangerous. There is the potential that public health workers who have knowledge of the identity of a rape victim may be compelled to testify to this information in legal proceedings against the woman for the illegal act of adultery, or zina.
Existing guidelines, which have been applied to gathering data for the purpose of surveillance, evaluation, research, and screening for violence, seek to reduce the risk of harm to victims of violence. The WHO’s safety guidelines for the conduct of research on violence against women (WHO, 2001, 2016b) include guidance for informed consent, privacy, and confidentiality, as well as direction on staff recruitment and training to prioritize the safety of participants and research teams. Identifying victims of violence and including them in data collection, the nature and site of the interaction between the respondent and the data collector, and methods of eliciting information must be carefully structured to minimize the risks of data collection, from those of being observed answering questions to those associated with having names on a list or in a database. For example, decisions about whether interviews should be conducted at the respondent’s home or another place should balance the preferences and safety of the respondent against the potential loss of confidentiality (Rosenbaum et al., 2006; Fraga, 2016).
(p. 625) The WHO guidelines also address the potential for psychological harm to research or surveillance participants due to the nature of the inquiry, such as recalling traumatic experiences (WHO, 2016b). Careful selection and specialized, extensive training of those responsible for collecting information on violence may improve the quality of data collected and reduce the risk of traumatizing the respondents (Cyr and Lamb, 2009), as well as knowing how to respond and what referral resources must be in place if a respondent becomes upset. Some best practices include the use of open-ended prompts, while minimizing option-posing, suggestive questions that often feel riskier or harmful to respondents (Cyr and Lamb, 2009).
Appropriate interpretation of findings from both research and programmatic data to help formulate policies to prevent violence and mitigate against its harm is also important. As noted in the WHO’s Intervention Research Recommendation G, “dissemination of results . . . should avoid stigmatizing or exacerbating risks faced by . . . vulnerable populations” (WHO, 2016b, 20). For example, the classic US 1990 National Family Violence Survey determined that women were as likely to report having used physical violence against their male partners as vice versa (Straus and Gelles, 1990). However, most acts of violence committed by women were defensive in nature, men were much more likely to perpetrate sexual abuse and coercive control than women, and the likelihood of injury to men was much smaller than that to women (Swan et al., 2008). Without this detail, data from the original study might be cited as exculpatory in trials of violence against women. Selective utilization of data is a challenge across all domains of policymaking; however, public health workers have a responsibility to uphold the integrity of data findings and, in doing so, guard against making the problem of violence worse.
While we recognize that measurement of the occurrence of violence and evaluation of interventions for violence are important steps in establishing evidence-based programs for violence prevention (WHO, 2014), data gathering on violence also should include attempts to measure the harm experienced by respondents as a product of the data gathering process itself. Assessment of the risks associated with data gathering for victims of violence will continue to contribute to the development of evidence-based standards for research and surveillance for this population. As we advocate for ethical public health surveillance to address violence as a public health issue, this raises the issue of individual versus communal benefit. Surveillance must be in the context of functioning systems that also respond to such cases of violence individually; the absence of such systems (or functioning systems) does not outright mean the inability for effective surveillance, but rather should lead to the linking of programs with efforts to ensure provision of selected services.
Addressing Violence through the Health System
The WHO (2014) has recognized victim identification, care, and support programs that reduce future harm to those affected by violence as one of the seven evidence-based “best buys” for violence prevention programs. As such, there are several key sets of (p. 626) recommendations for screening and identifying those at risk for, or affected by, violence (US Preventive Services Task Force, 2013; WHO, 2014), as well as those at risk of committing violence (Betz and Wintemute, 2015). Violence screening programs should be carefully tailored to the appropriate context, yet many of the providers in LMIC sites in which violence screening is advocated (e.g., antenatal clinics) are likely to lack the training, skills, and time to provide counseling for intimate partner violence. Furthermore, these resource-constrained settings may lack subsequent support mechanisms for victims of violence, such as welfare benefits, social services, alternative living arrangements, or effective legal mechanisms. In LMICs, workers who identify someone as having experienced interpersonal violence may have no options but to send them back to their abusive homes or neighborhoods.
In this instance, it is essential to articulate who benefits from screening or identification of those affected by violence. While information about violence can play a crucial role in advocacy efforts, the benefits to individuals screened or identified are not clear. At a minimum, providers should be trained to respond with some amount of counseling and to provide support for those who remain in abusive situations, even if no additional services are locally available (Friedman, 2016).
Many existing interventions for reducing violence, such as family counseling, require the involvement of other members of the victim’s family or community, and may even involve the perpetrator of the violence. Akin to individual counseling, considering the wishes of the victim is paramount; those experiencing or at risk of violence should have the opportunity to make informed decisions about the inclusion of other individuals in their family or community.
Ethical Challenges in Addressing Suicide
Suicide is an area of public health that often draws increased attention. Ethics challenges arise in the process of assessment and management of individuals’ suicide risk, delivery of interventions with a risk of adverse events, and balancing considerations of autonomy and safety. The WHO (2012) has advocated for the inclusion of questions on suicidal behaviors in population-based surveys as part of a strategy to improve case registration and when conducting research for suicide prevention. Studies have attempted to address the fear that inquiries about suicidal ideation may increase self-harm. Those studies so far suggest that asking about suicide does not bring about such an increase, although less is known about the impact of such questions in large-scale survey settings (Dazzi et al., 2014). As in all public health surveillance and research, if screening tools identify people at risk, appropriate referral is a minimum requirement, and in cases where imminent risk of harm is uncovered, public health professionals may need to ensure that emergency treatment is immediately available (as discussed in WHO guidelines).
(p. 627) The potential exclusion of those at heightened risk for suicide from participation in research due to concerns about the severity of their condition and the imminence of death can be problematic (Zimmerman et al., 2015). Suicide risk ought not constitute a barrier to participation in trials for interventions on mental health, in the same way that those at risk for death due to physical illness (e.g., end-stage cancer) are increasingly included in clinical trials. It is ethically imperative that opportunities to participate in research be equally distributed and accessible to all, including those with mental health issues, various ethnic or cultural backgrounds, or overlapping marginalizing identities. This is particularly the case for research studies that hold the prospect of direct benefit for an individual or community of individuals in need of public health attention and intervention. One of the constraints in research in this regard is the potential challenge to researchers in cases where participation is unable to prevent suicide-related harm, as of course will happen for much of medical research (IOM, 2002).
Another ethical dilemma occurs when respect for individual autonomy clashes with paternalism, or the need to provide the best care to further the well-being of patients (Kelly and Dale, 2011); this challenge emerges when those at imminent risk of self-harm refuse further treatment. In programs involving suicidal individuals, it is important to inform them and, when involved, their families about the possibility of involuntary hospitalization in case of imminent suicide risk. For example, seeking informed consent for treatment involving individuals at high risk of suicide due to compromised mental status, cognitive deficits, and impaired ability to judge reality (e.g., people with schizophrenia) poses a set of particularly difficult ethical challenges, and yet it is essential to appreciate that mental health challenges and suicide are deeply correlated (Appleby et al., 2001). Public health practitioners are required to balance risks and benefits of interventions, including involuntary treatment in the context of the importance of autonomy. The involvement of a legally acceptable representative or a patient advocate to provide consent when such involvement is appropriate, and the need for an informed consent process tailored to the participant’s capacity to understand (including the provision of adequate time for the participant to assimilate the informed consent process), are important considerations. For public health practitioners, the major practical ethical challenge remains the necessity of referral to care for those identified to be at risk of self-harm and the provision of emergent care for those at imminent risk of suicide. Specifically, in the context of preventing self-harm, paternalism can be justified and individual decision-making might be overridden.
Finally, public health models of suicide examine questions of the degree to which suicide is the result of individual factors versus social determinants. According to Scott Fitzpatrick (2018, 181), “[b]ecause many of the causes of suicide extend beyond individual behavior to the population level (for example, injustice, discrimination, mental illness) and relate to membership of various social groups and communities (for example, Indigenous; lesbian, gay, bisexual, transgender, intersex, queer; those in the criminal justice system) they can also be addressed through population-based strategies.” This model underscores the need, consistent with a public health approach, to also examine and intervene on social determinants in making progress toward suicide prevention.
(p. 628) Conclusion
It is essential that the global health community fully understand the ethical issues of public health interventions around violence. These have been defined for different types of violence, including interpersonal and self-directed violence. Despite recent efforts by the WHO and violence prevention professionals, many governments and the wider community fail to recognize that injuries caused by intentional behavior are no accident, that violence does not just happen, and that we can prevent these conditions in an ethical and meaningful way. Of course, it is critical not only to identify the determinants of violence, but also to be thoughtful about the ethics challenges that emerge in collecting data about them, as well as those that arise in addressing them.
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