So You Want to Start an Ethics Committee
Everything you need to know to establish a committee.
This webpage provides resources for a local health department (LHD) that is interested in establishing an ethics committee. Such a committee can serve as a foundation to guide health officials and their staff in weighing and making tough decisions. Additionally, an ethics committee can help a health department work towards fulfillment of the ethics requirement in the Public Health Accreditation Board (PHAB) Standards and Measures Version 1.5. This webpage contains a step-by-step guide for creating your ethics committee, examples of the kinds of issues a committee might address, and sample documentation from health departments that have established ethics committees. The Resources section at the bottom of the page includes a handout to share with LHD leadership to provide a rationale for establishing a committee, a list of expert-recommended introductory ethics resources, a summary of all the steps for establishing a committee. (Note: The sequence of the steps might vary somewhat depending on local circumstances.)
Consider identifying a public health ethics champion among health department staff who will take responsibility for demonstrating to leadership, other staff, and key community stakeholders the value of establishing a systematic, deliberate approach to addressing ethical issues as part of the decision-making process. The ethics champion could be a leadership level staff member, the health department director, or even the accreditation coordinator. The ethics champion can illustrate the value of an ethics committee to leadership by identifying a recent ethics issue the agency had to deal with and explaining how an ethics committee might have assisted. The champion can also serve as a facilitator of committee processes and as a liaison between the committee and LHD leadership.
- Make sure that leadership is educated on public health ethics. Some good introductory resources are suggested in the Training Tools section below.
- Get the “stamp of approval” from your board of health.
- Secure your health official’s acknowledgment of ultimate responsibility for the agency’s ethical decision-making process. This might take the form of any or all of the following:
- A public statement about your agency's ethical decision-making process
- Dedication of time, funds, or resources for ethics activities (training, committee establishment, committee meetings, etc.)
- Agreement to serve as chair of the committee or as the final reviewer of committee decisions
- Involvement in selection/appointment of committee members
Development of an ethics infrastructure must start within the health department. Make sure that all staff understand the key premises of public health ethics and your agency’s decision-making structure and process.
- Consider ethics training as part of an all-staff meeting, workforce development plan, and/or new staff orientation.
- Direct staff to background materials on public health ethics. (See Training Tools below.)
- If applicable, recruit a local university or hospital ethicist to provide additional training and subject matter expertise.
The exact size and composition of your ethics committee may depend on your agency’s size, the array of interests represented in your community, or the nature of the particular issue being addressed. Your committee may include members who rotate in and out depending on the particular issue but should include some core standing members to ensure continuity. A list of potential types of members is provided in the second “to do list” item below, but it should be noted that a committee does not have to include every single stakeholder described.
- Identify the necessary committee roles. Roles include:
- Ethics Chair/Coordinator: The chair will organize, facilitate, and schedule meetings; oversee the committee and ensure proper protocol is followed and appropriate interests are represented; manage the logistics of committee meetings and the deliberative process (i.e., sending out relevant case information, approving meeting minutes, documenting official decisions, etc.).
- Legal Counsel: Legal counsel participation will ensure that the committee is aware of relevant authorities and limitations on those authorities based on statutes, rules, and precedents. Ideally, this counsel should be local and have experience closely working with the LHD.
- Local Ethics Adviser: This local ethics adviser will help provide ethics perspective. An ethicist can be identified through either a local hospital or academic institution.
- Determine which agency staff and community external stakeholders should participate to ensure a wide range of perspectives. Possible external stakeholder and/or perspectives can include, but are not limited to:
- Ad-hoc members based on issue being deliberated
- Disability advocate
- Education (K-12 and higher education)
- Employee/employer relations representative
- Environmental health specialist
- Human resources officer, bargaining unit representative, and/or civil service representative
- Human services professional
- Institutional Review Board
- Law enforcement
- LGBT perspective
- Local government other than LHD
- Multiracial and ethnic perspectives
- Non-profit leader
- Sanitarian/environmental health specialist
- Vector control practitioner
It is essential that committee members have a good foundational understanding of public health ethics. To ensure this level of understanding, in addition to the other background materials recommended on this webpage, identify one or two other opportunities for committee members to obtain in-depth exposure to the ethical decision-making process.
- Provide committee members with annual training on public health ethics topics.
- Discuss case studies found in the literature or developed by committee members. (See Training Tools below).
Your committee needs to identify guiding principles and an ethics analysis framework to inform the committee’s deliberations. Ethics codes provide aspirational standards that the LHD can draw upon when considering different courses of action. The Public Health Leadership Society Principles of the Ethical Practice of Public Health (often referred to as the Public Health Code of Ethics) can serve as an important resource. In addition, professional codes of ethics may be useful (see examples in “to do” list below). Ethical analysis frameworks provide a process for identifying, analyzing, and resolving ethical and values dilemmas. There are several analysis frameworks available. For example, see the ethical analysis framework from Ruth Gaare Bernheim, Phillip Nieburg, and Richard J. Bonnie.
- Identify relevant codes of ethics; In addition to the Public Health Code of Ethics, some examples of other codes you might want to draw upon include the following:
- American College of Epidemiology Ethics Guidelines
- American Dental Association Code of Ethics
- American Medical Association Code of Ethics
- American Nurses Association Code of Ethics
- Belmont Report (ethical principles for the protection of human research subjects)
- National Commission for Health Education Credentialing Code of Ethics
- National Environmental Health Association Code of Ethics
- Choose an ethical analysis format that works for you. Some possible resources include:
- Ethics and the Practice of Public Health (Oxford University Press)
- The Ethical Dimensions of the Biological and Health Sciences (pp. 349-352)
- Ethics Primer (Northwest Association for Biomedical Research)
- A Framework for Ethical Decision Making (Santa Clara University)
- A Framework for Making Ethical Decisions (Brown University)
Your committee charter describes the purpose, processes, and structure of your committee. The document should explain the rationale for the committee and highlight the key components of the deliberative process. Adhering to a charter will assure quality and consistency for the committee.
Given the level of trust and responsibility granted to the committee, it is important to set up a clear, consistent process that the committee will follow for each case. The process should encompass all aspects of the decision-making mechanism from intake (submission of a specific ethics dilemma for review) to the transparent documentation of the committee’s review and recommendations.
- Determine what criteria must be met for the committee to review a case. (For example, describe the process by which health department staff or community members may submit an issue for consideration. Determine whether the committee or the LHD leader decides which issues the committee actually reviews.)
- Committee should acknowledge that final decision-making authority rests with the LHD leader and ultimately the Board of Health (or other governing authority such as mayor or city council). However, the committee’s recommendations are taken seriously.
- Set standards for membership terms, renewal, and turnover.
- Determine which committee roles are needed.
- Select an appropriate meeting frequency.
- Prepare for expedited review in emergency situations and lay out the procedures for how it will take place.
- Decide how results of committee deliberations and decisions will be documented, as PHAB accreditation requires documentation of a resolved ethical issue. Consider investing in an online system that assists with policy management and version control.
- Define confidentiality standards.
- Develop a process map that outlines steps taken in the deliberation, from initial submission of an issue to resolution of the case. A documented process or policy for addressing ethical issues is required for PHAB accreditation. Check out this example from Harris County, TX!
- Consider the role of conflict of interest disclosures and policies for reviewers.
- Develop appropriate forms to accompany committee processes (examples include intake form, closure form, conflict of interest form).
Resolving public health ethics issues requires skills that must be acquired through practice. Once you have all your “Ps” in order (policies, procedures, and paperwork), the best way to test the effectiveness of your committee is to start deliberating cases. You can do this through a discussion of case studies. CDC has a number of resources for case studies on its website, including a casebook, a case repository, and a training manual that includes cases. These materials can also be used to provide ongoing continuing education of committee members during periodic meetings in between discussion of ethics cases.
After your committee has gained a satisfactory level of comfort with the process, we recommend piloting the process with an actual ethics issue raised from within your department.
Just having a committee in place is not enough; you’ll need to make sure health department staff and community members are aware of the ethics committee and how it can serve as a resource for addressing ethics concerns.
- Develop a communications plan to promote the committee internally and externally. This should include informing your county/city-wide government about the ethics committee. See the below job aid, Getting the Word Out About Your Ethics Committee, for suggestions to inform your communications plan.
- If needed, contact NACCHO for continued guidance to keep your committee up and running.
- Don’t forget to document the deliberation and outcome of ethical issues. Documentation of a resolved ethical issue is required for PHAB accreditation.
- Got documentation? In the NACCHO Toolbox you can find examples of how other LHDs have established different types of programs and procedures. The Toolbox is a free online collection of materials and resources shared by members for use by other public health professionals. If you’d like to share your ethics deliberation process and how you developed it with other LHDs, we encourage you to post your ethics tools in the Toolbox.
Training Tools for Public Health Ethics
This handout contains a comprehensive list of expert-recommended public health ethics resources.
Training Tools for Public Health Ethics
- Barry-Eaton District Health Department
- Clark County Public Health
- Centers for Disease Control and Prevention, Public Health Ethics Unit
- Harris County Public Health & Environmental Services
- Johnson County Department of Health and Environment
- Mahoning County Board of Health
- Presidential Commission for the Study of Bioethical Issues
- San Diego County Public Health