Accrediting Ethics Competencies in Schools and Programs of Public Health: A Gap in Council on Education for Public Health Criteria

At the 2016 annual meeting of the American Public Health Association (APHA), the Council on Education for Public Health (CEPH) presented its new accreditation criteria for schools and programs of public health. All schools and programs were required to comply with these new criteria by January 2018. These new criteria shifted from the previous accreditation standards that required schools and programs of public health to create competencies, and then a curriculum, that addressed the core public health disciplines to the requirement to create a curriculum from “competencies to translate that knowledge into effective day-to day practice.” ¹ This change marked “the biggest change to public health curricula since the 1940s.” ²

The new CEPH competencies explicitly mention ethics in only one competency, and only as one aspect of a larger issue, policy making: “Discuss multiple dimensions of the policy-making process, including the roles of ethics and evidence.” ³ Other than this single explicit mention, ethics can be interpreted to be implicit in several other competencies, when one acknowledges that several competencies evoke such traditional ethical domains as values, fairness, and relational and communication skills (ie, getting along with others).

We believe that the revisiting of the CEPH accreditation criteria was a missed opportunity to acknowledge and include explicit ethics competencies as required for adequate training in public health. Although the public health literature contains an extensive conversation about the nature and definition of public health ethics, ^{4 –12} these discussions are rendered moot if schools and programs of public health do not teach these values and skills to future public health practitioners.

Both of the authors are professors in an accredited school of public health at a Jesuit university (St. Louis University) that is committed to social justice and ethics. One author (S.S.C.) has developed and delivered masters-level public health ethics courses for the past 8 years and has seen firsthand positive reception and the practical benefit that these ethics courses bring to public health students, as well as the challenge of keeping these courses in the curriculum due to the increasingly robust competencies demanded of schools and programs of public health that do not include ethics competencies. This experience is not unique. In 2008, Klugman ¹³ wrote that his public health ethics course was pulled from the curriculum because ethics had not been required for the previous CEPH accreditation criteria, which did not mention ethics at all.

At this critical juncture for curriculum design in schools and programs of public health, we make the case that public health ethics competencies should be explicitly included in CEPH competencies. We argue that the exclusion of explicit ethics competencies does not align with 2 stated purposes of the new CEPH criteria: (1) to shift from accreditation based on knowledge to accreditation based on skills and competencies and (2) to align public health training with the needs of the public health workforce. ² On the contrary, public health ethics has already been conceptualized in terms of skills and competencies in the public health ethics literature in a way that easily fits into CEPH’s approach to competencies, and empirical evidence and practice demonstrate that the public health workforce needs public health ethics training. Finally, implicit inclusion is not enough. We argue that CEPH should include competencies explicitly about ethics in its new accreditation criteria; by not doing so, public health trainees risk not being adequately prepared for the challenges of public health practice in the 21st century.

The Shift From Knowledge to Competencies: Ethics as Competencies

One goal of the new CEPH accreditation criteria is to shift from its previous focus on traditional curricular domains of public health knowledge, such as biostatistics, epidemiology, and social and behavioral sciences, to skills-based competencies that can be taught in any way that a school or program of public health sees fit. Perhaps ethics was excluded as a competency because of uncertainty about what it means to teach ethics or doubt about whether ethics can be conceived of as competencies and skills as opposed to a domain of knowledge. Although traditional bioethics programs have focused on ethics as a knowledge domain, there is no reason why ethics cannot also be construed as a set of skills. For many years, public health scholarship, guidance documents, and reports have articulated ethics skills in public health. Although a complete survey of this literature lies outside the scope of this commentary, we discuss some of the more prominent and recent examples of articulated public health skills and competencies.

In 1992, the Centers for Disease Control and Prevention funded the Council on Linkages Between Academia and Public Health Practice to develop the Core Competencies for Public Health Professionals, defined as “foundational skills desirable for professionals engaging in the practice, education, and research of public health.” ¹⁴ These competencies explicitly include ethical competencies in numerous places under 3 of its 8 domains (analytic/assessment skills, public health science skills, and leadership and systems-thinking skills), unlike the recent CEPH competencies that include ethics under just 1 domain (policy making).

In addition, although public health scholarship contains ample articulations of public health ethical values or principles and the ethical theories that underpin or justify them, the focus on articulating skills in public health ethics, often understood as applying these principles and theories thoughtfully and effectively in real contexts, is also prevalent. Starting in the early 2000s, several scholars published studies defining what Lee ¹⁵ called “practice-based frameworks” for public health ethics. Under this category, Lee included approaches that outlined “foundational values and provide operating principles that direct a course of thoughtful action (or series of considerations) for practitioners faced with ethical quandaries in the public health sphere.” Scholars who published articles about this type of approach, according to Lee, started with Kass ⁶ in 2001, followed by Childress et al ⁵ and Upshur ¹⁶ in 2002, and continued from there.

At nearly the same time, the Institute of Medicine ¹⁷ published Who Will Keep the Public Healthy? a report that called for the identification of skills in public health ethics. In response, the Greenwall Foundation funded the University of North Carolina School of Public Health to identify these skills, which were published by the Public Health Leadership Society in 2004 as Skills for the Ethical Practice of Public Health. ¹⁸ Derived from the Core Competencies and the Public Health Code of Ethics, ¹⁹ these skills include:

1. The ability to identify an ethical issue

2. Ethical decision-making, including identifying and weighing harms and benefits of potential actions

3. Understanding the full spectrum of the determinants of health

4. Understanding basic ethical concepts such as justice, virtue, and human rights

5. Building and maintaining public trust

The document goes on to articulate more specific skills that follow from each of the 12 principles in the Public Health Code of Ethics. In a similar vein, Lee ²⁰ articulated 4 basic ethics skills that she argues are necessary for all public health personnel:

Identify the ethical dimensions of public health activities.

Articulate the ethical dimensions and dilemmas inherent in efforts to protect the public’s health.

Determine a path forward, especially when values and motivations conflict.

Implement and evaluate the solution to allow for course corrections and the addition of new information should the need arise.

Both skill sets notably differ from both the implicit ethics in the CEPH competencies and the explicit ethics in the Council on Linkages Between Academia and Public Health Practice Core Competencies. First, they cut across various domains or categorical competencies. In doing so, they demonstrate how ethics skills can be useful and important for many, if not all, other public health skills, from policy making to conducting research, and from leadership to cultural competency. They can be taught as case analyses (real or hypothetical), internship projects, policy-making exercises, role plays, or analyses of historical or contemporary issues. Second, they demonstrate that ethics need not be taught as a type of knowledge but can reflect the transition from knowledge domains to practical competencies that mark the greater shift in public health education and accreditation.

Although complete consensus is lacking on the ethical skills that should be taught and assessed by schools and programs of public health, as well as on the principles and values that should underlie them, ample resources are available for use by schools and programs of public health to develop courses or classes to teach ethical skills and competencies. ²¹

Bridging the Gap Between Public Health Training and Practice: Ethics at the Center

CEPH documents illustrate that a further goal of the new criteria is to achieve better alignment between public health training and public health practice. ² By omitting ethics from its competencies, CEPH is implying that ethics training is not necessary to meet this goal. It could be argued that just because ethical skills in public health are asserted and defined does not mean they are important or useful to public health practitioners. On the contrary, empirical studies of the ethical challenges that face public health professionals have consistently found that ethical challenges are frequent and central to their practice and that professionals often feel unprepared to meet these challenges. ^{22 –25} In one notable example, a 2014 US job task analysis conducted by the National Board of Public Health Examiners found that ethics was the third-highest-rated domain identified by respondents. ²⁴ Similar surveys with similar findings have been conducted internationally in Japan, Ghana, Canada, and Italy. ^{26 –29} More research needs to be conducted in this area, but what we know so far from the on-the-ground experiences of public health professionals is clear. Public health professionals face numerous ethical challenges in their professional lives, and they feel the need for training to face these challenges.

In addition to the voiced need for public health ethics training by public health professionals, we can ascertain the importance of ethical skills to public health practitioners by examining the ways that they are certified and their departments are accredited. The National Board of Public Health Examiners, in response to its job task analysis, revised the Certified in Public Health content domains in 2017 and greatly increased the explicit assessment of ethics. ³⁰ Ethics assessment is included in at least 10% of the new examination, which falls under the domain of “law and ethics.” This domain includes such skills as “apply basic principles of ethical analysis to issues of public health research, practice, and policy” and “apply social justice and human rights principles when addressing community need,” among others. Ethical components also appear in several other domains: “apply ethical considerations in developing communication plans and promotional initiatives” (communication domain); “develop a mission, goals, values, and shared vision for an organization or community in conjunction with key stakeholders” (leadership domain); and “assess how the values and perspectives of diverse individuals, communities, and cultures influence individual and society health, behaviors, choices, and practices” (health equity and social justice domain). ³⁰

In addition to the centrality of ethics in certifying public health professionals, ethics is central to the accreditation of public health departments. The Public Health Accreditation Board’s measures include 11.1.2A, a measure “to assess the health department’s policies and process for the identification and resolution of ethical issues that arise from the department’s program, policies, interventions, or employee/employer relations.” ³¹

Likewise, the National Association of County and City Health Officials states on its website that “health officials and their staff must be ready to handle ethical dilemmas that arise in day-to-day practice. Ethical considerations underlie numerous aspects of public health practice, ranging from staffing decisions at local health departments to distribution of vaccines during pandemics to media strategies related to sensitive subjects such as obesity.” ³²

Further evidence of the centrality of ethics to public health practice can be found in the pronouncements and actions of numerous agencies responsible for funding and overseeing public health practice. The Centers for Disease Control and Prevention has a standing Public Health Ethics Committee and originally funded the Public Health Leadership Society, which was responsible for developing the Public Health Code of Ethics. In addition to adopting the Public Health Code of Ethics, APHA has had an ethics committee since the 1980s. It was originally a special primary interest group (the Bioethics Forum) but has been a fully fledged APHA section (the Ethics Section) since 2014. ³³

In 2008, the World Health Organization (WHO) published an article on the contribution of ethics to public health. The article stated, “[S]ince it was founded 60 years ago, ethics has been at the heart of WHO’s mission to protect and promote the global community’s health,” and lists key issues in public health ethics. ³⁴ Published studies connecting ethical issues to public health practice are also coming out of several countries, notably Australia, Europe, India, and Scotland. ^{35 –38} Public Health Reviews, the official journal of the Association of Public Health in the European region, published 2 themed issues on public health ethics, the most recent one in 2012. ³⁹

It is clear that if a stated goal of the new CEPH accreditation criteria is to better align public health training with the needs of the public health workforce, then public health ethics training is needed by that workforce to meet the needs of accreditation, certification, funders, and everyday public health practice. Thus, CEPH’s neglect of public health ethics in its new competencies is not in line with this stated goal.

Ethics Education: Implicit or Explicit?

Although we may have established that ethics is central to public health training and practice, one could assume that the ethics implicit in numerous public health skills, including the skills articulated by CEPH, is sufficient to “sneak” ethics into curricula. Lee ²⁰ calls this implicit approach to ethics training “hidden curriculum.” On the contrary, an implicit acknowledgment of ethics is not enough. The aforementioned 2003 Institute of Medicine report stated that “the barriers to teaching ethics are substantial and, if not required, it is likely that ethics will not be taught in any meaningful way.…An uncoordinated ethics curriculum can easily be neither broad nor deep; it can be an inch wide and an inch deep.” ¹⁷ Thomas argued that if taught intentionally, ethics “holds the promise of training students to recognize hidden ethical assumptions, to consider them critically, and to design and implement research and interventions that more fully achieve a particular ethical perspective.” ⁴⁰ On the other hand, if taught accidentally, there lies a “danger that unethical perspectives will be uncritically adopted by students and then perpetuated in the practice of public health.” ⁴¹

We believe that an acknowledgment of the importance of ethical competencies for public health training and practice should lead directly to a commitment to requiring them as part of public health education. CEPH should therefore include public health ethics as an explicit competency or set of competencies in later revisions of its criteria. Our recommendation is open to which explicit ethical competencies should be incorporated into CEPH criteria, as well as how they should be incorporated (as a cross-cutting domain or as their own domain), because determining ethics competencies should be based on an inclusive process with the right persons at the table. That the outcome of the consultative process used by CEPH diverged so greatly from numerous other conversations among public health stakeholders who recognized the centrality of ethics for public health training and practice suggests that the CEPH process may have left key stakeholders out of their consultations.

Conclusion

The new CEPH criteria are intended to achieve 2 goals: (1) shift from knowledge domains to competencies and (2) bridge the gap between public health training and public health practice. Excluding explicit ethics competencies is problematic in light of both goals. Evidence suggests that ethics training is crucial to the successful practice of public health and that public health ethics has been articulated in terms of skills in the published literature. Finally, implicitly assuming the ethical underpinnings of the existing CEPH competencies is likely to have minimal effect on the training of public health professionals.

Ultimately, the biggest barrier to adequate ethics education in schools and programs of public health is not a lack of resources, lack of interest, or lack of understanding of ethics but, rather, the lack of emphasis that is being placed on this content from those who have the power to shape curricula. In 2002, Callahan and Jennings argued that “the time has come to more fully integrate the ethical problems of public health into the field of public health and…into bioethics.” ⁴¹ In 2019, we believe that now is the time to initiate this integration—when accrediting bodies are reflecting on and shifting their ways of evaluating schools and programs of public health. If CEPH were to respond to these arguments and explicitly incorporate ethics competencies into its requirements for public health programs, the passion and the expertise needed to incorporate public health ethics into the curricula would closely follow. And the current pressure to minimize or eliminate public health ethics from many curricula would transform into an incentive to think creatively about its growth.