Hms 195 - Public Health Ethics

Becca Oliveira

HMS 195- Public Health Ethics

Dena Davis

Midterm Exam

October 19, 2017

• Ramping up public education and hoping it reaches all the women who need it
• Providing government subsidized free folic acid to women of child-bearing age who want it
• Adding folic acid to the public water supply

Which of these options would you support, and why?  Be sure to use the various decision ladders and principles in the text in explaining your answer.

        Spina bifida can range from very mild cases to people who are born with paralysis of their lower bodies; requiring wheelchairs and often resulting in bladder and/or bowel incontinence. In the more severe cases, spina bifida can be a devastating and expensive disease. According to an article titled “Health care expenditures of children and adults with spina bifida in a privately insured U.S. population” by Ouyang et al., the average incremental medical expenditures comparing patients with spina bifida and those without were $41,460 per year at age 0, $14,070 at ages 1-17, $13,339 at ages 18-44, and $10,134 at ages 45-64. Children ages 1-17 years with spina bifida had average medical expenditures 13 times greater than children without spina bifida. Adults with spina bifida had average medical expenditures three to six times greater than adults without spina bifida in the privately insured population. Despite the exact causes of spina bifida still being unknown, we do know that getting sufficient folate (called folic acid when taken as a supplement) has been identified as a significant source of prevention.

        I believe that the best option in the prevention of spina bifida would be through the addiction of folic acid to the public water supply. When evaluating the three options provided for the prevention of spina bifida, I utilized the moral considerations in public health presented in chapter 1. Several moral considerations play important roles in the analysis and assessment of public health activities. The first moral consideration is if the decision of adding folic acid to the public water supply would produce benefits. It has been proven that women who take folic acid supplements before and during the first three months of pregnancy, reduce their risk of having a baby with spina bifida by 70%. Through extensive research I also found that folic acid has been known for treating very common conditions such as folate deficiency, anemia, vitamin B12 deficiency. It may also treat rarer conditions such as sickle cell anemia and thalassemia. These benefits also meet the second moral consideration in public health: avoiding, preventing, and removing harm.

        The third moral consideration in public health is if the decision is producing the maximal balance of benefits over harms and other costs (often called utility). The amount of benefits that would be provided by adding folic acid to public water is countless, while there is no known harmful effects on any population, including children and senior citizens. Adding folic acid to the public water supply would also be relatively cheap, and therefore not impose a burden on the physical cost of this decision. Rather than just balance the benefits and harms of adding folic acid to the public water supply, this decision allows the health benefits to heavily outweigh any possible harm that may be caused. Along with the balance of benefits over harm, comes the fourth moral consideration: distributing benefits and burdens fairly (distributive justice) and ensuring public participation, including the participation of affected parties (procedural justice). Adding folic acid to the public water supply ensures that anyone who wants or needs it, will have access to it. This decision also allows for public to chose to participate or not participate in the intake of the vitamin. Women of all child bearing ages will receive the sufficient levels of folate to help prevent spina bifida, while men and children will also benefit from the intake of the extra vitamin as it often is insufficient in a normal diet. Those who chose not to take part in the consumption of the the public water supply, which I believe they have no reason not to, will still have the option of purchasing filtered and bottled water.

        Adding folic acid to the public water supply may arise issues with the fifth moral consideration in public health: respecting autonomous choices of actions, including liberty of action. It may be argued that not everyone might agree or want the added folic acid, similar to the controversy over added fluoride in public water supplies. People argue that fluoride should not become a precedent for the government adding more and more things to the water supply and that the whole population shouldn’t have to take folic acid just because some people need it. Some proponents of a model of balancing principles view may view this strategy as a conflict between respect for autonomy, on the one hand, and several other principles including especially beneficial, but also utility, and justice, all of which have to be balanced against autonomy and liberty in implementing such a strategy. However, autonomy itself can be defined as the ability of the person to make his or her own decisions, and each individual still maintains the right to chose whether or not to consume from the public water supply. Additionally, if the added folic acid has no harm to the population, I believe that there is no reason to not want to take folic acid, as it is proven to only help you. Therefore, even in this case I still support the addition of folic acid to the public water supply.

        The sixth moral consideration is protecting privacy and confidentiality, which does not directly apply to this scenario. The seventh moral consideration is keeping promises and commitments. While folic acid cannot cure spina bifida, it has been proven to help prevent it, and reduce the chances of a baby being born with it. I believe that adding folic acid to the public water supply will decrease the number or babies born with this defect, as numerous women who were not educated on the benefits of folic acid or did not have the access to it, will now receive its benefits whether they are aware of it or not. Creating a larger population of women getting sufficient levels of folate will result in less babies being born with spina bifida, thus keeping the promise of reducing and preventing the birth defect.

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