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PowerPoint Presentation on article Anti-vax-tax
Final Case Presentation (15 minutes): Each student will be assigned an ethical case on a current topic in public health ethics. Students will present their analysis using the ethical framework and their recommendations on how to respond to the case at hand. Student presenters will use powerpoint or other visual presentation slides to communicate their analysis from the perspective of their assigned stakeholder.
Here’s the guide on how to breakdown the slides after reading the article:
Problem Statement
Landscape Assessment
Stakeholder Analysis
Values Assessment
[Rapid analysis: write the second part of the values assessment for this case. Choose one additional value, define it, and succinctly apply it to the case, making clear any differential interpretations by your stakeholders]
Childhood Obesity Education Campaign
STUDENT EXAMPLE CASE – PLEASE DO NOT DISTRIBUTE
Problem Statement
State X is suffering from a childhood obesity epidemic with 1 in every 4 child being obese, and up to 40% of children in minority groups being obese.
With the limited health literacy of children and the required motivation and incentive for children to change their health for the better, is a social marketing campaign enough to generate change for children to make informed healthy food choices and improving health literacy?
Landscape assessment
What we know:
Obesity rates for kids in State X
Social media approach (showing kids being unhealthy and sedentary w/ unhealthy habits)
Increased obesity rates among minority groups
What we don’t know:
Programs already in place to help combat obesity
Budget for creating social media marketing campaign
No plan to enhance health literacy than the recommended Engage, Educate, Empower and Enable approach by the Institute of Medicine.
Social dynamic of cities in this state (rural versus suburban, and crime and violence levels)
Stakeholder Analysis
Stakeholders in this proposed social media campaign
The Children
The Parents
The local health advocates
State Health Officials
Competing social media advertisers
Complimentary social media advertisers
Real estate owners
Website & social media platform owners
Value Assessment
Values Chosen for the Child Stakeholder in mind
Equity
Will Social economic status as well as perceived health literacy affect the way minority children adhere to the social media message compared to others?
Beneficence
Could the marketing that depicts the children being unhealthy be perceived as negative and effect efficacy and motivation to change?
Duty
How responsible are the children for taking control of their own health before and after being subjected to the health marketing?
Principles and Criteria
: How well would the media campaign be received by the intended audience? How well is this viewed by all stakeholders?
: Does the intended option work towards reducing obesity rates effectively, or create more social issues?
: Does this option reach the intended audience most effectively through its channel of communication and delivery?
Opinions & Criteria
Our options for a social marketing decision
: Continue on with the intended currently planned social media campaign.
: Reject the proposed social marketing
: Tweak the social marketing to be more engaging and inform how to achieve healthy eating habits, rather than shaming bad ones by holding after school programs focused on exercise and eating right.
Recommendations
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Total | -1 | 6 |
Interpreting the Choice
With our known knowledge and intended purpose of encouraging health, using option 3 would be my suggestion as it seems less offensive to the intended audience, whilst also showing what good health habits looks like an putting a positive spin on it.
Option 2 would be objectively bad as the obesity epidemic simply perpetuates itself.
Option 1 would probably have some impact, but may be received poorly by some, and others in low socio-economic status may not possess the necessary media channels to receive the information.
Questions???
References
Centers for Disease Control and Prevention. National Center for Health Statistics (NCHS). National Health and Nutrition Examination Survey Data. Hyattsville, MD: U.S. Department of Health and Human Services,2007.
Centers for Disease Control and Prevention. Basics about childhood obesity.
http://www.cdc.gov/obesity/childhood/basics.html
Robert Wood Johnson Foundation’s Trust for America’s Health. F as in fat: How obesity threatens America’s future, 2010. http://healthyamericans.org/reports/obesity2010/
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Case 3: Anti-Vax Tax
In January of 2015 over 100 people in the US contracted measles, mostly from an outbreak of the
disease at California’s Disneyland theme park.16 The outbreak was spread in part by people who
had refused to accept vaccinations for themselves or their children. In July of 2015, the
Washington State Department of Health confirmed the first death from measles in the United
States in 12 years.17
Vaccinations for diseases like measles, mumps, and rubella have kept these diseases in check in
the Western world for more than 50 years. While these diseases used to run rampant and threaten
adults and children alike, they had all but been defeated up until the early 2000s.18 Guided by a
pop-culture movement that cited, among other things, a (now retracted) scientific paper linking
autism with the vaccine for measles, mumps, and rubella (MMR),19 people began delaying
vaccinations for their children or refusing them outright. While numerous studies have shown
that childhood vaccinations are safe and reliable bulwarks against disease,20 the number of
parents refusing vaccines has continued to climb.
Anti-vaccination groups also cite a worrisomely close partnership between the pharmaceutical
companies making the vaccines and the Federal Drug Administration (FDA) which oversees the
safety of vaccines. They maintain that the FDA does not sufficiently supervise the
implementation of precautions after the drugs are on the market for human use.21 They also cite
the existence of the National Vaccine Injury Compensation Program (NVICP) as evidence that
vaccines are legally recognized as possibly causing suffering that requires compensation by the
government.22 (They also suggest that the NVICP incorrectly shields pharmaceutical companies
from justified lawsuits.)
As the number of unvaccinated people grew, so did the risk that a carrier of one of these diseases
could spread the disease more rapidly. If the human “herd” lost its increased immunity to the
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16 Stephen Reinberg, Low Vaccination Rates and Disney Measles Outbreak, HealthDay Reporter, March 16, 2015,
http://www.webmd.com/children/vaccines/news/20150316/low-vaccination-rates-likely-behind-disney-measles-
outbreak-study
17 Maggie Fox, Washington Woman is First US Measles Death in 12 Years, NBC News, July 3, 2015,
http://www.nbcnews.com/health/health-news/woman-dies-measles-first-us-death-12-years-n385946
18 National Center for Immunization and Respiratory Diseases (Division of Viral Diseases), Measles History,
Centers for Disease Control and Prevention, November 3, 2014, http://www.cdc.gov/measles/about/history.html
19 Fiona Godlee, Jane Smith, and Harvey Marcovitch, Wakefield’s article linking MMR vaccine and autism was
fraudulent. BMJ 2011;342:c7452, January 6, 2011, http://www.bmj.com/content/342/bmj.c7452
20 Centers for Disease Control and Prevention, Vaccine Safety, March 27, 2015,
http://www.cdc.gov/vaccinesafety/index.html
21 Shannon Barber, No, I Am Not an Anti-Vaxxer, But I Do Understand Their Stance, Addictinginfo.com, February
3, 2015, http://www.addictinginfo.org/2015/02/03/no-i-am-not-an-anti-vaxxer-but-i-do-understand-the-stance/
22 Barbara Loe Fisher, Why Vaccine-Injured Kids Are So Rarely Compensated, Mercola.com Health News,
December 13, 2008, http://articles.mercola.com/sites/articles/archive/2008/12/13/why-vaccine-injured-kids-are-
rarely-compensated.aspx
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disease, even those who were vaccinated could be at risk. And with an increased number of life-
threatening illnesses comes increased healthcare costs. For instance, the cost of the measles
outbreak is high, potentially costing up to $10,000 per case. In a healthcare system like the one in
the United States, these costs are absorbed not only by the families of the sick children, but may
also be “shared” by all those paying for health insurance in the form of increased premiums.23
Citing the unfairness of saddling those who vaccinate their children with the increased health
insurance costs from those who do not, a team of doctors and lawyers are now proposing a tax on
those who refuse vaccinations.24 Since vaccinations have been established to be safe for most
children and vaccination costs are covered by all health insurance plans, they argue that the
choice not to vaccinate one’s children should be discouraged by creating a tangible disincentive
to opt out of vaccination, regardless of whether any members of the family actually contract a
vaccine-preventable disease. Furthermore, such a tax would allow the healthcare system to
recoup the costs directly from those whose choices potentially increase the costs. In this way, the
proposed tax would work much like a tax on cigarettes that would fund lung cancer treatment.
Anti-vaccination advocates and other libertarian thinkers, however, argue that such a tax
interferes with important principles of liberty.
Indeed, people generally have the right to refuse medical treatment for themselves as well as
their children—some advocates believe that they should have the right to refuse vaccines as well.
They argue that the state should not take a position on treatments where some people have
serious doubts about the scientific data, and that the tax amounts to economic coercion. There is
no such tax, for instance, on foods that may increase the risk of diabetes or heart disease (which
are far more costly diseases). And there are no societal sanctions on those who refuse to cover
their mouths when they cough or come to work when they are sick with the flu, even though the
flu is a communicable disease with a much higher risk of transmission than measles, mumps, or
rubella.
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23 Charlotte Moser, Dorit Rubinstein Reiss, and Robert Schwartz, Funding the Costs of Disease Outbreaks Caused
by Non Vaccinations, June 3, 2014, Journal of Law, Medicine, and Ethics,
http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2445610##
24 Ibid.
Providing care to Undocumented immigrants
STUDENT EXAMPLE CASE – PLEASE DO NOT DISTRIBUTE
Problem Statement
Mr. Villalobos, a 37-year-old, Spanish-speaking migrant worker from Central Mexico.
No health insurance. Has a daughter with chronic illness he pays out of pocket to treat.
No previous health issues, develops sudden congestive heart failure/cardiomegaly.
Provided emergency care in hospital, stabilized and prescribed medication.
After being discharged, followed up with a Migrant Health Center and the attending physician decided he needed care outside of the Health Center’s resources.
Mr. Villalobos needs a heart valve replacement, but cannot afford the surgery due to his lack of health insurance and eligibility for Medicaid.
This begs the question…
Is the healthcare system denying the life-saving procedure to Mr. Villalobos due to his lack of medical insurance a justifiable ethical decision in the case of providing care to undocumented immigrants in the United States?
Landscape Assessment
What we do know:
Mr. Villalobos does not have health insurance
He does not have any prior medical history
He is relatively fit and healthy
He has been in the United States for less than a year (“some months”)
He works 10 to 12 hours a day in local mushroom houses
Has a wife and five children
Has confirmed congestive heart failure/Cardiomegaly (enlarged heart)
He has been prescribed medications to prevent clotting and control his heart rate
Presents symptoms with minimal exertion despite being on medication
Needs a heart valve replacement for condition to improve
Landscape Assessment (cont.)
What we don’t know:
Mr. Villalobos’s daughter’s condition (We don’t know how much he is paying out of pocket)
Age of Mr. Villalobos’s children
Details about Mr. Villalobos’s wife
Mr. Villalobos’s family’s feelings about the situation
Mr. Villalobos’s family medical history
Mr. Villalobos’s income
If Mr. Villalobos has any friends/family that live in the United States that could potentially help him
If Mr. Villalobos is able to continue receiving his life-saving medications for his heart failure
Landscape Assessment (cont.)
Assumptions:
Mr. Villalobos has not tried to apply for any type of insurance or healthcare coverage
Mr. Villalobos has paid for his daughter’s medical care out of pocket
Mr. Villalobos wants to have the heart valve replacement done
Mr. Villalobos’s family supports the surgery being done
Mr. Villalobos does not qualify for Medicaid
Mr. Villalobos is not healthy enough to return to Mexico for treatment
Mr. Villalobos is not healthy enough to continue working at this job
Mr. Villalobos does not have any friends or family in the United States in a position to help him
Related Laws and Policies
Pennsylvania’s Medical Assistance program
Under the Pennsylvania Health Law Project
Has some limitations, but exceptions for certain people to qualify
The Affordable Care Act (2012)
Holds limitations for undocumented individuals, such as ACA subsidies, CHIP, and Medicaid Limitations
Illegal Immigration Reform and Immigrant Responsibility Act (1996)
Undocumented individuals present in United States for 180 days but less than 365 days must remain outside of United States for 3 years unless granted a pardon
Increases deportation risks
What is Pennsylvania’s medical assistance program?
The MA program is Pennsylvania’s version of Medicaid.
Individuals can only qualify if they’re “Lawfully present” or of “qualified” immigration status that have already lived in the United States for five years.
In this case, Mr. Villalobos does not qualify, has only been in the United States a few months, and his condition would not allow him to live for five additional years untreated.
Though he is able to receive emergency MA as he did initially, he does not qualify for this particular program.
Stakeholder Analysis
Mr. Villalobos
Needs to have good health to support his family
Does not want to put his life at risk by not receiving care
Mr. Villalobos’s wife
Stayed with the 5 children in Central Mexico
Mr. Villalobos’s treatment could impact her
Mr. Villalobos’s Family (especially chronically ill daughter)
Requires support from Mr. Villalobos
Medical care providers
Recognize Mr. Villalobos needs heart valve replacement, but are conflicted with limited resources
Federal Healthcare system
Limitations on ACA and other related laws and policies
Values Assessment
Autonomy
Mr. Villalobos should not be denied the opportunity to make a life-saving decision for himself, and should not have the decision made for him due to lack of resources/insurance.
Equity and Social Justice
Mr. Villalobos should have the same opportunity for healthcare as everyone else.
Distributive Justice
Mr. Villalobos should be able to get the heart valve replacement surgery if resources are available in the United States.
Criteria: From perspective of Mr. Villalobos
Harm
Which option will reduce overall harm the most?
Which option will improve Mr. Villalobos health-related issues?
Which option will improve Mr. Villalobos’s financial harm the most?
Efficiency
Which option saves the most money?
Which option would be efficient in helping Mr. Villalobos keep his job?
Quality of Life
Which option would make Mr. Villalobos feel the best in terms of physical health?
Which option will allow Mr. Villalobos to live a long, happy, healthy life?
Which option would allow Mr. Villalobos to help his family’s quality of life?
Option 1: Status Quo
Mr. Villalobos doesn’t act on getting the heart valve replacement surgery
He continues working despite being symptomatic
He continues making money to support his family
Quality of life remains on a steady decline
High risk for major organ failure and death in a short amount of time
Option 2: Apply for General Assistance Related MA
Pennsylvania adopted a Medicaid expansion in 2015
Despite Mr. Villalobos not qualifying for Medicaid, he does qualify for benefits from the expansion.
Does not require the five year waiting period, unlike the MA program
He could receive his medication that stabilizes his condition.
He falls into the category of General Care Medical Assistance:
“Adults with Temporary Disabilities (GA-related NMP) – Adults with low enough income and resources may qualify for this category if a doctor completes an Employability Assessment Form (PA 1663) and indicates the applicant has a temporary disability which impacts their ability to work.” (Casserly, D., & PHLP, 2017)
Option 3: Receive EMA to cover ongoing care
In 2004, DHS issued Operations Memorandum # 040301 clarifying that CAOs (County Assistance Officers) have the authority to approve Emergency medical assistance for emergency ongoing care, and this is still in effect today
Does not need to disclose immigration status or qualify for Medicaid to qualify for EMA ongoing treatment
This includes:
Stating the need for treatment is immediate, and that without treatment/surgery his life is at risk.
Doctor must write EMC letter of seriousness of condition resulting from lack of proper treatment.
Must include in letter expensive medical emergencies that will arise without treatment.
Summary of Ethical Options
Value Status Quo Apply for general MA Apply for EMA for ongoing care
Harm – – + ++
Efficiency – – +
Quality of life – + ++
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Recommendation
Option 3: Receive EMA to cover ongoing care
This option would give Mr. Villalobos the highest potential to get the heart valve replacement surgery
Improves his quality of life the most in the long term.
Most efficient for his financial status, and allows him to return to work without suffering from symptoms.
He may still have to take medication, but he won’t be symptomatic with minimal exertion and he will be able to continue his work and have an overall improved condition.
What happens if Mr. Villalobos still doesn’t receive any medical care despite his qualifications?
If Mr. Villalobos doesn’t get coverage and goes untreated, his condition will reach emergency care status regardless. Getting covered by ongoing MA would be the best preventative measure to avoid this from happening, but he will still end up getting emergency medical care in the end. Thus, option 3 is still the most ideal option.
References
Casserly, D., & PHLP. (2017). Health Care for Immigrants: A Manual for Advocates in Pennsylvania. Retrieved from http://www.phlp.org/wp-content/uploads/2016/05/Immigrant-Health-Care-Manual-For-Advocates-05.2016
Ku, L., & Jewers, M. (2015, August 12). Health Care for Immigrant Families: Current Policies and Issues. Retrieved from https://www.migrationpolicy.org/research/health-care-immigrant-families-current-policies-and-issues
Zong, J., Zong, J. B., Batalova, J., & Hallock, J. (2018, February 27). Frequently Requested Statistics on Immigrants and Immigration in the United States. Retrieved from https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states#HealthInsurance
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