Ethical challenges and moral distress among field epidemiologists

Abstract

Background As ‘disease detectives’ and directors of public health programs, field epidemiologists play essential roles in protecting public health. Although ethical issues receive considerable attention in medical and research settings, less is known about ethical challenges faced by field epidemiologists in public health programs. Similarly, little is known about moral distress among field epidemiologists, i.e., situations in which they are constrained from acting on what they know to be morally right. Moral distress is strongly associated with empathy fatigue, burnout, reduced job retention, and disengagement. To better understand ethics training needs for field epidemiologists, in February 2019, members of TEPHIConnect, an online and mobile networking platform for Field Epidemiology Training Program (FETP) alumni, were invited to participate in an anonymous survey about ethical challenges and moral distress. Results Among 126 respondents from 54 countries, leading causes of ethical dilemmas included inadequate informed consent (61%), inequitable allocation of resources (49%), and conflicts of interest (43%). These occur primarily in settings of disease outbreaks (60%); research (55%); and public health programs at the state, province, or national level (45%) or community level (43%). Work-related moral distress was reported by 91% of respondents, including 26% who experience it “frequently” or “almost always.” Field epidemiologists working in low- and low-middle income countries were more likely to report moral distress “frequently” or “almost always” than those in higher-income countries (33.0% vs 9.1%, P = 0.006). The most common perceived contributors to moral distress included excessive stress and work demands (30%) and inadequate support from leaders (25%). Conclusions Field epidemiologists face significant work-related ethical challenges, which are endemic to public health and political systems. A substantial proportion of field epidemiologists also experience some degree of moral distress, often in association with these challenges. These findings indicate an unmet need among field epidemiologists for support in navigating ethical challenges, as well as for resources to address the human and professional consequences of moral distress.

‘Telling them “that’s what it says in the guidance” didn’t feel good enough’: moral distress during the pandemic in UK public health professionals

“… 26 The inability to be transparent was a theme Cooke et al found associated with moral distress in epidemiologists. 16 Our results replicated this, and suggest that it is not just the withholding of information, but the active communication of untruthful or misleading information, that can cause moral distress in the public health profession at large. This could be a problem inherent to public health communication, wherever its ultimate goal is to change people’s behavior, as there could be a temptation to simplify or exaggerate the facts in order to achieve that goal.…”

“… 26 Our finding that conflicts between the pursuit of health and the pursuit of other goods (2Ai) were a major driver of this distress, echoes a subtheme of Cooke et al . 16 This kind of moral conflict may be difficult to avoid, since its resolution will often necessarily fall beyond the remit of public health staff, who are professionally bound to prioritize the pursuit of health.…”

“…Being constrained into inaction (2B), as a cause of moral distress, accords with previous studies in public health and healthcare professionals. 15 , 16 , 26 This is a potentially unlimited source of moral distress, as there is always more good that could be done, and limits on a public health professional’s ability to do it.…”

“…Sunderland et al identified moral distress associated with a perceived lack of political will for ‘upstream’ health promotion in Australian and Canadian health promotion practitioners, 15 and Cooke et al identified moral distress associated with excessive work-related stress, unsupportive, ineffective or corrupt leaders, inadequate resources, and poor access to public health services in field epidemiologists from 54 countries. 16 However, neither study explored ways to address the identified moral distress, and, to date, no studies have looked at the public health professional workforce as a whole, or at the impact of the COVID-19 pandemic.…”

Moral distress and injury in the public health professional workforce during the COVID-19 pandemic

“…One qualitative study of Australian and Canadian health promotion practitioners retrospectively identified moral distress themes from interview transcripts, and an international survey of field epidemiologists found that 91% reported work-related moral distress, with 26% experiencing it ‘frequently’ or ‘always’. 16 , 17 …”