Public Health

Models may not only represent, but also influence their targets in important ways. While models’ ability to influence outcomes has been studied in relation to economic models, often under the label “performativity”, we argue that this phenomenon also pertains to epidemiological models, such as those used for forecasting the trajectory of the COVID-19 pandemic. After identifying three ways in which a model by the COVID-19 Response Team at Imperial College London (Ferguson et al. 2020) may have influenced scientific advice, policy, (...) and individual responses, we consider the implications of epidemiological models’ performative capacities. We argue, first, that performativity may impair models’ ability to successfully predict the course of an epidemic; and second, that it provides an additional respect in which these models can be successful, namely by changing the course of an epidemic. (shrink)

In Italy, during the first wave of the Covid-19 pandemic, the Italian Society of Resuscitators and Pain Therapists (SIAARTI) and the Italian National Bioethics Committee (CNB) published ethical guidance on the allocation of scarce intensive care resources. In this paper, we outline and compare these documents in detail, highlighting differences and similarities. In particular, we argue that major differences exist with respect to the principles and values underpinning the documents and the normative allocation criteria proposed. Conversely, similarities can be traced (...) with respect to a functional rather than substantial endorsement of the age criterion, the importance of transparency, and the consideration over healthcare professionals’ responsibility regarding allocative decisions. In conclusion, we argue that Italy has lacked a comprehensive and publicly-accountable policy articulating principles and operational criteria geared to strengthen the “ethical preparedness” of the country in dealing with current and possible future public health emergencies. (shrink)

The COVID-19 pandemic has led to intense conversations about ventilator allocation and reallocation during a crisis standard of care. Multiple voices in the media and multiple state guidelines mention reallocation as a possibility. Drawing upon a range of neuroscientific, phenomenological, ethical, and sociopolitical considerations, the authors argue that taking away someone’s personal ventilator is a direct assault on their bodily and social integrity. They conclude that personal ventilators should not be part of reallocation pools and that triage protocols should be (...) immediately clarified to explicitly state that personal ventilators will be protected in all cases. (shrink)

Pro-life advocates commonly argue that fetuses have the moral status of persons, and an accompanying right to life, a view most pro-choice advocates deny. A difficulty for this pro-life position has been Judith Jarvis Thomson’s violinist analogy, in which she argues that even if the fetus is a person, abortion is often permissible because a pregnant woman is not obliged to continue to offer her body as life support. Here, we outline the moral theories underlying public health ethics, and examine (...) the COVID-19 pandemic as an example of public health considerations overriding individual rights. We argue that if fetuses are regarded as persons, then abortion is of such prevalence in society that it also constitutes a significant public health crisis. We show that on public health considerations, we are justified in overriding individual rights to bodily autonomy by prohibiting abortion. We conclude that in a society that values public health, abortion can only be tolerated if fetuses are not regarded as persons. (shrink)

At the beginning of the COVID-19 pandemic, high hopes were placed on digital contact tracing. Digital contact tracing apps can now be downloaded in many countries, but as further waves of COVID-19 tear through much of the northern hemisphere, these apps are playing a less important role in interrupting chains of infection than anticipated. We argue that one of the reasons for this is that most countries have opted for decentralised apps, which cannot provide a means of rapidly informing users (...) of likely infections while avoiding too many false positive reports. Centralised apps, in contrast, have the potential to do this. But policy making was influenced by public debates about the right app configuration, which have tended to focus heavily on privacy, and are driven by the assumption that decentralised apps are “privacy preserving by design”. We show that both types of apps are in fact vulnerable to privacy breaches, and, drawing on principles from safety engineering and risk analysis, compare the risks of centralised and decentralised systems along two dimensions, namely the probability of possible breaches and their severity. We conclude that a centralised app may in fact minimise overall ethical risk, and contend that we must reassess our approach to digital contact tracing, and should, more generally, be cautious about a myopic focus on privacy when conducting ethical assessments of data technologies. (shrink)

As many Western countries emerged from initial periods of lockdown in spring 2020, they had brought COVID-19 infection rates down significantly. This was followed, however, with more drastic second and third waves of viral spread, which many of these same countries are struggling to bring under control, even with the implementation of further periods of lockdown. Could this have been prevented by policymakers? We revisit two strategies that were focus of much discussion during the early stages of the pandemic, and (...) which were implemented in several Western countries, albeit in a weakened form. These strategies both proceed by targeting certain segments of the population, while allowing others to go about their lives unhindered. The first suggests selectively isolating those that would most likely suffer severe adverse effects if infected – in particular the elderly. The second involves identifying and quarantining those who are likely to be infected through a contact tracing app that would centrally store users’ information. We suggest that both strategies showed promise in preventing the need for further lockdowns, albeit in a significantly more stringent form than anything that was implemented in Western countries. We then proceed to an ethical evaluation of these more stringent policies. We contend that selective isolation strategies face severe ethical problems due to its discriminatory nature, while the ethical issues with a more aggressive contact tracing regime can be mitigated. This analysis has implications for how to respond effectively and ethically to future pandemics, and perhaps contains lessons on how to successfully emerge from our current predicament. (shrink)

Drawing on the SAGE minutes and other documents, I consider the wider lessons for norms of scientific advising that can be learned from the UK’s initial response to coronavirus in the period January-March 2020. I highlight three key issues: the normative force of scientific advice, the role of reasonable worst-case scenarios, and the limits of independence and neutrality. A recurring theme is the difference between normal scientific advising and scientific advising in extremis, when a significant fraction of a country’s population (...) face immediate peril and there is no adequate pre-existing plan for managing the risk. Through reflection on these issues, I formulate seven proposals for effective scientific advising in extremis. In an epilogue, I consider what the implications of these proposals would have been for the UK’s response to the “second wave” of late 2020. (shrink)

This book offers a philosophically-based, yet clinically-oriented perspective on current medical reasoning aiming at 1) identifying important forms of uncertainty permeating current clinical reasoning and practice 2) promoting the application of an abductive methodology in the health context in order to deal with those clinical uncertainties 3) bridging the gap between biomedical knowledge, clinical practice, and research and values in both clinical and philosophical literature. With a clear philosophical emphasis, the book investigates themes lying at the border between several disciplines, (...) such as medicine, nursing, logic, epistemology, and philosophy of science; but also ethics, epidemiology, and statistics. At the same time, it critically discusses and compares several professional approaches to clinical practice such as the one of medical doctors, nurses and other clinical practitioners, showing the need for developing a unified framework of reasoning, which merges methods and resources from many different clinical but also non-clinical disciplines. In particular, this book shows how to leverage nursing knowledge and practice, which has been considerably neglected so far, to further shape the interdisciplinary nature of clinical reasoning. Furthermore, a thorough philosophical investigation on the values involved in health care is provided, based on both the clinical and philosophical literature. The book concludes by proposing an integrative approach to health and disease going beyond the so-called “classical biomedical model of care”. (shrink)

Background Viral pandemics present a range of ethical challenges for policy makers, not the least among which are difficult decisions about how to allocate scarce healthcare resources. One important question is whether healthcare workers (HCWs) should receive priority access to a vaccine in the event that an effective vaccine becomes available. This question is especially relevant in the coronavirus pandemic as governments and health authorities prepare to distribute a COVID-19 vaccine. Main text In this article, we critically evaluate the most (...) common ethical arguments for granting healthcare workers priority access to a vaccine. We review the existing literature on this topic, and analyse both deontological and utilitarian arguments in favour of HCW prioritisation. For argument’s sake, we focus in particular on the distribution of a COVID-19 vaccine. We also explore some practical complexities attendant on arguments in favour of HCW prioritisation. Conclusions We argue that – independent of the specific empirical characteristics of COVID-19 (i.e., virulence and prevalence) – there are deontological and utilitarian cases for prioritising HCWs. Indeed, the widely held view that we should prioritise HCWs represents an example of ethical convergence. Complexities arise, however, when considering who should be included in the category of HCW, and who else should receive priority in addition to HCWs. (shrink)

With by far the lowest population density in the United States, myriad challenges attach to healthcare delivery in Alaska. In the “Size, Population, and Accessibility” section, we characterize this geographic context, including how it is exacerbated by lack of infrastructure. In the “Distributing Healthcare” section, we turn to healthcare economics and staffing, showing how these bear on delivery—and are exacerbated by geography. In the “Health Care in Rural Alaska” section, we turn to rural care, exploring in more depth what healthcare (...) delivery looks like outside of Alaska’s major cities. This discussion continues in the “Alaska’s Native Villages” section, which specifically analyzes healthcare in Alaska’s indigenous villages, some of the smallest and most isolated communities in the United States. Though many of the ways we could improve Alaskan health care for Alaskan residents are limited by its unique features, the “Justice and Healthcare Delivery” and “Technology and Telemedicine” sections consider ways in which certain policies and technology—including telemedicine—could mitigate the challenges developed in previous sections. (shrink)

Disparities exist in the health, livelihood, and opportunities for the 46-60 million people living in America’s rural communities. Rural communities across the United States need a new energy and focus concentrated around health and health care that allows for the designing capturing, and spreading of existing and new innovations. This paper aims to provide a framework for policy solutions to build a healthier rural America describing both the current state of rural health policy and the policies and practices in states (...) that could be used as a national model for positive change. (shrink)

By examining the global public good nature of pandemic preparedness we can identify key social justice issues that need to be confronted to increase citizens’ voluntary compliance with prevention and mitigation measures. As people tend to cooperate on a voluntary basis only with systems they consider fair, it becomes difficult to ensure compliance with public health measures in a context of extreme inequality. Among the major inequalities that need to be addressed we can find major differences in the extensiveness and (...) intensiveness of quarantine experiences, lack of opportunities to participate in common efforts, hardship in complying with disease control recommendations, and an unfair distribution of the cooperative surplus. (shrink)

Decision-Making Capacity First published Tue Jan 15, 2008; substantive revision Fri Aug 14, 2020 In many Western jurisdictions the law presumes that adult persons, and sometimes children that meet certain criteria, are capable of making their own medical decisions; for example, consenting to a particular medical treatment, or consenting to participate in a research trial. But what exactly does it mean to say that a subject has or lacks the requisite capacity to decide? This question has to do with what (...) is commonly called “decisional capacity”, a central concept in health care law and ethics, and increasingly an independent topic of philosophical inquiry. -/- Decisional capacity can be defined as the ability of subjects to make their own medical decisions. Somewhat similar questions of capacity arise in other contexts, such as capacity to stand trial in a court of law and the ability to make decisions that relate to personal care and finances. However, the history behind the more general legal notions of capacity to stand trial and capacity to manage one’s life is different and operates somewhat differently in law (Roth, Meisel, & Litz 1977; Zapf & Roesch 2005). For the purposes of this discussion the notion of decisional capacity will be limited to medical contexts only; most notably, those where decisions to consent or to refuse treatment or participation in clinical research are concerned. (shrink)

In response to crises, people sometimes prioritize fewer specific identifiable victims over many unspecified statistical victims. How other factors can explain this bias remains unclear. So two experiments investigated how complying with public health recommendations during the COVID19 pandemic depended on victim portrayal, reflection, and philosophical beliefs (Total N = 998). Only one experiment found that messaging about individual victims increased compliance compared to messaging about statistical victims—i.e., "flatten the curve" graphs—an effect that was undetected after controlling for other factors. (...) However, messaging about flu (vs. COVID19) indirectly reduced compliance by reducing perceived threat of the pandemic. Nevertheless, moral beliefs predicted compliance better than messaging and reflection in both experiments. The second experiment’s additional measures revealed that religiosity, political preferences, and beliefs about science also predicted compliance. This suggests that flouting public health recommendations may be less about ineffective messaging or reasoning than philosophical differences. (shrink)

Opioid litigation continues a growing public health litigation trend in which governments seek to hold companies responsible for population harms related to their products. The litigation can serve to address gaps in regulatory and legislative policymaking and in market self-regulation pervasive in the prescription opioid domain. Moreover, prior opioid settlements have satisfied civil tort litigation objectives of obtaining compensation for injured parties, deterring harmful behavior, and holding certain opioid manufacturers, distributors and pharmacies accountable for their actions. In this way, opioid (...) litigation represents progress over prior public health litigation campaigns involving tobacco, lead paint, and asbestos, which had more limited tort litigation effects. Although opioid litigation is not a comprehensive solution to the opioid crisis, it can complement other strategies and infuse much needed money, behavior changes, and public accountability for prescription opioid and related harms. (shrink)

Volume 20, Issue 7, July 2020, Page 180-182.

A short reflection on respects in which philosophers are particularly, if not uniquely, well positioned to address certain ethical and epistemological controversies pertaining to the coronavirus.

Certifications of immunity are sometimes called “immunity passports” but are better conceptualized as immunity-based licenses. Such policies raise important questions about fairness, stigma, and counterproductive incentives but could also further individual freedom and improve public health. Immunity licenses should not be evaluated against a baseline of normalcy, ie, uninfected free movement. Rather, they should be compared to the alternatives of enforcing strict public health restrictions for many months or permitting activities that could spread infection, both of which exacerbate inequalities and (...) impose serious burdens. This Viewpoint presents a framework for analyzing the ethics of immunity licenses. (shrink)

Commentary about the role of AI in bioethics for the 10th anniversary issue of AJOB: Empirical Bioethics.

Iris Marion Young’s classic paper on the phenomenology of pregnancy chronicles the alienating tendencies of technology-ridden maternal care, as the mother’s subjective knowledge of the pregnancy gets overridden by the objective knowledge provided by medical personnel and technological apparatuses. Following Fredrik Svenaeus, the authors argue that maternal care is not necessarily alienating by looking specifically at the proper attention paid by sonographers in maternal care when performing ultrasound examinations. Using Martin Heidegger’s philosophy as a theoretical lens, the authors argue that (...) sonographers who cultivate technical mastery, build patient rapport, explain the process and significance of the ultrasound, and understand the patient’s world are able to provide excellent patient care. The authors utilize Hans-Georg Gadamer’s hermeneutics to show how sonographers can frame the ultrasound in a way that acknowledges both the subjective knowledge of the mother and the objective data obtained by the sonographer through the use of technology. Ultimately, the authors argue that the common practice of framing the ultrasound as the chance to “meet the baby” is inappropriate, as it exacerbates the tendency to regard objective knowledge as the only legitimate knowledge in medical contexts. They recommend a more balanced approach that elicits a fusion of horizons between the patient’s subjective knowledge and the objective data that is obtained by the sonographer via the ultrasound, thus respecting and bolstering patient autonomy. (shrink)

We can say that it is necessary for every human being to walk towards the comprehension of the contingent and limited reality of the human person, starting with those whose work involves dealing with patients, as well as those who dedicate themselves to bioethical reflection, and even the patients themselves. In this way, at the time when these people face a situation of pain and suffering, they will be able to assume it with integrity and strength, always choosing to protect (...) the valuable gift of human life, and not simply looking for it. to make the pain disappear as it may, tearing it up at the root, often ending up with a human life, be it at the moment of conception, as an embryo, with disabilities, sick or aging. -/- Podemos decir que es necesario que todo ser humano camine hacia la comprensión de la realidad contingente y limitada de la persona humana, empezando por aquellos cuyo trabajo involucra el trato con pacientes, así como quienes se dedican a la reflexión bioética, e incluso los mismos pacientes. De esta manera, en el momento en que estas personas se enfrenten a una situación de dolor y sufrimiento, podrán asumirla con entere-za y fortaleza, optando siempre por proteger el valioso don de la vida humana, y no simplemente buscando hacer desaparecer el dolor a como dé lugar, arrancándolo de raíz, muchas veces terminando con una vida huma-na, sea en el momento de la concepción, como embrión, con discapacidades, enferma o envejecida. (shrink)

Elderly refugees in Jordanian healthcare settings are a vulnerable group. Most of them come from a collectivist culture where family members are the main source of care. Many elderly refugees can no longer work as they did, and are in need of professional intervention from social workers who will take account of their cultural values and beliefs. This exploratory study seeks to understand the role that religion has in the lives of displaced elderly refugees and the impact of those perspectives (...) on how they make sense of their circumstances. Using a qualitative design the methodology drew upon focus group discussions, semistructured interviews and ethnographic participant observation in the gathering and analysis of data. The study highlights the important role that religious beliefs and values play both in maintaining and enhancing elderly refugee’s sense of community, security and mental well-being, and the fundamental importance of the same in their interactions with professionals. A key finding is that religious sensitivity and awareness are critical to good social work practice with religious elderly refugees from the Arab world. It is also suggested that the findings of this study can be transferred to other populations and age groups. (shrink)

This paper relates human rights to public health ethics and policies by discussing the nature and moral justification of human rights generally, and the right to health in particular. Which features of humanity ground human rights? To answer this question, as an alternative to agency and capabilities approaches, the paper offers the “fundamental conditions approach,” according to which human rights protect the fundamental conditions for pursuing a good life. The fundamental conditions approach identifies “basic health”—the adequate functioning of the various (...) parts of our organism needed for the development and exercise of the fundamental capacities—as the object of a human right. A human right to basic health entails human rights to the essential resources for promoting and maintaining basic health, including adequate nutrition, basic health care, and basic education. Duty bearers include every able person in appropriate circumstances, as well as governments and government agencies, private philanthropic foundations, and transnational corporations. (shrink)

This paper looks at the Catholic justification of medical interventions in ectopic pregnancies. The paper first shows that the way how Double Effect Reasoning is often applied to ectopic pregnancies is not consistent with the way Aquinas introduces this mode of reasoning. The paper then shows certain problems in common defences of the use of salpingectomies. The paper then re-evaluates the medical interventions used in the management of ectopic pregnancies, with both a focus on the aim of the treatment and (...) the timing of the treatment. (shrink)

In this chapter I explicate and evaluate the concept of medical error. Unlike standard philosophical approaches to analyzing medical phenom- ena in the abstract, I instead address medical error specifi cally within the context of an embodied social world. I illustrate how, as a deeply contex- tual concept, medical error is inextricably tied to the social conditions— and concrete, powerful interests—of the particulars in which it is found. -/- I begin with an analysis that demonstrates the relational quality of medi- (...) cal error, as a functional, outcome-oriented concept, evaluating the origin and context of the term’s emergence, and connecting it to a similarly contextual concept, “standard of care.” I move on to note the concern- ing implications of medical error identifi cation and measurement when viewed through an intersectional standpoint. To do so, I discuss what intersectional approaches can help reveal about our contemporary social world of medicine and public health. Intersectional approaches, as I will explain, focus on how intersections of social identity can unmask social structures that negatively impact groups and individuals. It appears, as -/- I will suggest, that disparities in social goods (e.g., social standing, edu- cation, wealth) complicate our identification of medical error, itself, and compound concerns of equity and access to medical goods for those who have diminished expectations for health. (shrink)

Brummett and Salter propose a useful and timely taxonomy of clinical ethics expertise (2019). As the field becomes further “professionalized” this taxonomy is important, and the core of it is right. It needs some refinement around the edges, however. In their conclusion, Brummett and Salter rightly point out that there is a significant difference between the ethicist whose recommendations are procedure- and process-heavy, consensus-driven, and dialogical and the authoritarian ethicist whose recommendations flow from “private moral views” (Brummett and Salter, 2019). (...) This admission doesn’t go far enough. Brummett and Salter’s taxonomy fails to capture the notion that offering recommendations whose normative force is moral is different in kind from recommendations whose normative force is non-moral, such as those recommendations that are free of moral content or justified by convention. The difference is in kind, not scale. I argue further that clinical ethics expertise, if possible, consists at least in offering recommendations whose normative force is moral. These two claims imply that the taxonomy fails to cut clinical ethics expertise at the joints: the ethicist who offers justified non-moral normative recommendations is a different kind of ethicist from the one who offers justified moral normative recommendations, yet both are categorized as clinical ethics experts. I finish by offering a refinement of the taxonomy that more precisely categorizes clinical ethicists. (shrink)

Conscientious objection in healthcare has come under heavy criticism on two grounds recently, particularly regarding abortion provision. First, critics claim conscientious objection involves a refusal to provide a legal and beneficial procedure requested by a patient, denying them access to healthcare. Second, they argue the exercise of conscientious objection is based on unverifiable personal beliefs. These characteristics, it is claimed, disqualify conscientious objection in healthcare. Here, we defend conscientious objection in the context of abortion provision. We show that abortion has (...) a dubitable claim to be medically beneficial, is rarely clinically indicated, and that conscientious objections should be accepted in these circumstances. We also show that reliance on personal beliefs is difficult to avoid if any form of objection is to be permitted, even if it is based on criteria such as the principles and values of the profession or the scope of professional practice. (shrink)

Animal-derived constituents are frequently used in anaesthesia and surgery, and patients are seldom informed of this. This is problematic for a growing minority of patients who may have religious or secular concerns about their use in their care. It is not currently common practice to inform patients about the use of animal-derived constituents, yet what little empirical data does exist indicates that many patients want the opportunity to give their informed consent. First, we review the nature and scale of the (...) problem by looking at the groups who may have concerns about the use of animal-derived constituents in their care. We then summarise some of the products used in anaesthesia and surgery that can contain such constituents, such as anaesthetic drugs, surgical implants and dressings. Finally, we explore the problem of animal-derived constituents and consent using Beauchamp and Childress’ four principles approach, examining issues of autonomy, beneficence, nonmaleficence and justice. Disclosing the use of animal-derived constituents in anaesthesia and surgery is warranted under Beauchamp and Childress’ four principles approach to the problem. Although there exist systemic and practical challenges to implementing this in practice, the ethical case for doing so is strong. The Montgomery ruling presents additional legal reason for disclosure because it entails that patients must be made aware of risks associated with their treatment that they attach significance to. (shrink)

Medical billing has become so intertwined with patient care, that in order to be truly committed to the physician's telos of managing a patient's medical suffering, it is imperative that physician ought to reexamine many of the ethical considerations about billing.

This chapter explains the interrelationship between a clearly formulated philosophy of hospice care and the possibility of ethical reflection and analysis in hospice care. In so doing, it proposes that the reader consider the care given by hospices to be a special kind of practice that contains and infers its own ethics. Terminal care given by hospices is also situated in a larger society, and therefore its internal values interact with a broad set of social values; the practice of hospice (...) care interacts with many other social practices, some that support hospice and some that are in tension with it. This situation of internal ethical coherence within a context of social and cultural plurality provides an important orientation and framework for ethical decision making in, and about, hospice care. (shrink)

This chapter offers an explanation of, and approach to, respecting confidentiality as an ethical obligation in the practice of hospice and palliative medicine. Understood in the context of coincident ethical obligations to maximize clinical benefit, avoid preventable harm, and restore moral agency, respecting confidentiality is embedded in the most basic philosophical precepts that define hospice and palliative care. How to respect confidentiality in everyday practice, however, can be a matter of unusual complexity. As such, following a brief conceptual framework, the (...) chapter explores ways to employ the framework in the service of patients and families in clinical practice. While various regions and nationalities will have legal and regulatory requirements informing the definition and practice of respecting confidentiality, this chapter focuses instead on respecting confidentiality as an ethical value. Readers are encouraged to supplement the content of this chapter with the relevant requirements that apply in their practice location. (shrink)

Communication is a key mediating variable in achieving the primary goal of palliative care: optimizing quality of life by reducing suffering in patients and families experiencing serious and life-limiting illness. Through analysis of its conceptual foundation and internal values, this chapter demonstrates that palliative care is an inherently moral practice, seeking to ameliorate suffering by restoring and supporting the moral agency of patients and families. Because therapeutic communication is a necessary condition for achieving this goal, it constitutes a core ethical (...) obligation of palliative care providers and organizations. Ethical communication among healthcare providers, and between providers, patients, and family members, can be considered a form of care, subject to the same ethical norms that pertain to all clinical care: respect personhood, minimize harm, and maximize benefit. Using the concepts of sensitivity, truthfulness, confidentiality, and deliberation, a framework for ethical communication is presented. Because an excessive focus on communication outcomes often diverts attention away from the communication process itself, raising the risk for confrontation and stalemate, the ethical framework presented here emphasizes the importance of process, suggesting that communication processes are ethically significant apart from the outcomes they may produce. (shrink)

Advance directives are often used to help patients articulate their end-of-life treatment preferences and guide proxy decision makers in making health care decisions when patients cannot. This case study and commentary puts forth a situation in which a palliative care consultation team encountered a patient with an advance directive that instructed her proxy decision maker to consider estate tax implications when making end-of-life decisions. Following presentation of the case, the authors focus on two ethical issues: 1) the appropriateness of considering (...) patients' financial goals and values in medical decision making and 2) whether certain kinds of patient values should be considered more or less relevant than others as reasons for expressed treatment preferences. Clinicians are encouraged to accept a wide range of patient values as relevant to the clinical decision-making process and to balance the influence of those values with more traditional notions of clinical harm and benefit. (shrink)

This paper describes novel tobacco control laws passed in New York City in 2017. These laws are designed to improve the city's strategy of using price to decrease tobacco consumption, and over time, change the city's landscape by making tobacco less accessible.

When Congress passed HIPAA, it did not intend to constrain public health's data sharing in the same way as clinical or payers. In fact, HIPAA recognizes data sharing with public health as a matter of national priority and shields this function from its reach. However, a health department may offer services that bring it within HIPAA's purview, such as running a Children's Health Insurance Program or a laboratory that bills electronically. When this is the case, HIPAA requires all information and (...) departments be subject to HIPAA unless the public health authority chooses to hybridize. Health departments might re-assess their coverage and elect to become a hybrid entity, thereby restricting HIPAA to only where required and removing barriers to information sharing with communities. (shrink)