1. Introduction

Public health (PH) policy and interventions are usually the product of controversy, and quite often they also remain surrounded by controversy as they are implemented ¹. Along with scientific considerations, political and economic interests as well as the collateral ethical conflicts shape the routine of public health practice. The societal approach of public health raises not only conflicts between individual and community interests and values ², but also questions of autonomy and social justice, debates over the meaning of health and well-being for different groups of people, disputes over the rationale of the community, reconciliation of multi-cultural values, disagreement on the limits of research, etc. ³

All these issues pose ethical dilemmas that PH professionals must learn how to deal with. They need to learn how to balance the competing interests and conflicting values and choose the best option or, as C. Potter puts it, the "lesser evil" among them ⁴. On the other hand, due partially to its multidisciplinary nature, the ethical background and the moral values that PH professionals have will differ ⁴. It is hence also important to recognise the moral values that each of us brings along to the profession and maximise the synergies of each of the disciplines' ethical traditions to solve population health challenges.

If we agree that being able to identify, analyse and cope with moral ambiguity are necessary skills that all PH professionals must possess, then PH ethics must be taught and trained during the academic public health training programme ⁵. Knowing the ethical frameworks and principles that should guide PH practice and professional integrity should remain a relevant part of the teaching. But since ethical values only have a value to society when put into practice, we need to inculcate ethical reflection as a habit and use learner-centred methods of joint decision making and collective learning through additional approaches, like for instance case-studies, group discussion and role playing ^4,6.

Despite teaching ethics in PH programmes being nowadays widely acknowledged as essential, evidence shows that even in countries with a longer tradition of teaching PH ethics, such as the United States, the United Kingdom, ethics education and ethical competencies of PH professionals are far from being the norm ^7,8,9. In Europe, the Working Group of Ethics and Values in Public Health, a collaboration of ASPHER (Association of Schools of Public Health in the European Region) and the Ethics in Public Health section of the European Public Health Association (EUPHA) have done a great effort over the last 10 years to address this issue. Along with a row of articles, seminars and workshops on the topic, they research and advocate for ethics training in the PH curriculum in Europe, including the proposal of a set of minimum PH competences that include ethical skills ⁸. Overall though, current European masters in public health do not regularly include modules in PH ethics and training in PH ethics in Europe cannot be said to be yet at the core of public health programmes ¹⁰. In Spain, the Ethics working group of the Spanish Society of Public Health and Health Administration together with the Víctor Grífols y Lucas Foundation, have organised several workshops, each of them accompanied by the later publication of a booklet ^{11,12,13,14,15}. The situation regarding teaching PH ethics in formal PH training in Spain is relatively unknown although supposed to be insufficient ¹⁶.

In contrast with the overall erratic implementation of public health ethics training, the range of resources coming from the universities providing such training is impressive. Along with several textbooks intended for both students and instructors covering the most relevant ethical issues of PH, a series of manuals including well-documented real cases for ethics reflection and discussion have been published in the last 5-15 years. However, for those PH professionals trying to become familiar with PH ethics and/or searching for teaching materials on the topic, this abundant choice of textbooks can at first pose an additional difficulty, especially when lacking time.

The present paper has two aims. First, to examine and describe the extent to which Spanish accredited masters of public health (MPH) have adopted ethic courses in their curricula. Second, to review the main teaching and/or learning resources on public health ethics available in English language and to summarize their content.

2. Methods

In order to describe the PH ethics teaching in the MPH in Spain we explored the internet sites from all current official MPH in Spain. We reviewed their online programmes for the past and/or present academic year (2017-2018, 2018-2019) and looked for any mention of public health ethics. Specifically, we searched for terms beginning with "etic-" (Spanish for "ethic-"). We searched first within the subjects' titles and afterwards within specific subject's programme, i.e. we examined whether there was any specific subject of PH ethics and later whether there was any mention of PH ethics in other subjects' agenda or programme. We also assessed whether the particular subject was mandatory or optional.

Regarding the search for teaching resources for PH ethics we employed several strategies: a) Google and Google Scholar search using different combinations of key words (i.e. "public AND health AND ethics", "ethics AND preventive AND health", "ethics AND preventive AND medicine", etc.); b) references review from previously retrieved articles regarding PH ethics education on Pubmed; c) references and recommended materials within the retrieved manuals and books. For each potentially pertinent document found, we assessed summary or description and index. We then searched all the resources deemed relevant for PH ethics teaching on the Internet to look for their online availability. When open access was not attainable, we assessed their availability, delivery options and price in common electronic commerce platforms and stores.

We reviewed their indexes and contents and examined the general structure of each resource and whether cases for discussion were included. The geographical context of each source was assessed based on the authors' affiliations and the context of the cases and PH general information included. We also aimed to assess the overall value as a teaching tool of each of the books in the context of MPH education. This perceived value encapsulates the authors' personal judgement and is based on whether the book content is deemed appropriate to use as part of the instruction material for students and/or suitable to prepare cases for discussion and debate sessions in class. Finally, in order to summarise the topics covered by the books we drew up a list of all topics included in the indexes, subsequently grouped similar topics into specific areas in PH and PH ethics and compiled a general list.

3. Results

We identified 14 masters of public health (MPH) currently active in Spain (Table 1). Most MPH are designed as on-site courses, two of them are online and two combine both modalities. The number of ECTS (European Credit Transfer and Accumulation System) credits was 60 for all except one of them that had 120.

Table 1 List of masters of public health in Spain active in 2018 and their teaching institution, teaching modality and number of European credits (ECTS). 

Six (48.9%) MPH had a specific mention of PH ethics on the title of at least one of their subjects, and a further MPH mentioned PH ethics as one of the main topics of a subject. Hence, according to their online programs, a total of 7 (50.0%) of the current MPH in Spain are teaching PH ethics. One of the MPH includes two subjects with mention of PH ethics. Ethics is taught together with other aspects of PH in all cases: as part of a general introduction to PH in 3 of the MPH, together with legal issues and PH policy in 4, and with communication in PH in another 2 (in some of the MPH ethics is taught with both communication and legal issues). In all 7 of the MPH the courses on PH ethics or mentioning PH ethics were mandatory. However, one of these MPH also includes an optional subject of PH ethics.

A total of 12 textbooks on public health ethics were reviewed. Table 2 includes a list of them in alphabetical order by their (first) author or editor and some general characteristics including online availability and purchase options and price. Only 4 of them are available to free download as a PDF and two of them are difficult to acquire from Spain through regular electronic commerce platforms. Approximate prices range between 17 and 130 euros, and two of the volumes available online cannot be purchased as printed books.

Table 2 Main characteristics of the textbooks and manuals on public health ethics. 

1 Price for the softcover format unless otherwise specified.

About half of the books are structured in two or more sections or parts, each of them including several chapters (Table 3). Some of the books are a collection of essays or already published articles dealing with specific aspects of ethics in PH and five books include cases for discussion or case studies. In most cases, each chapter (or article) is written by a different author or group of authors. The textbooks that include cases for discussion or case studies are specifically designed to use in teaching settings, i.e. the information for each case is organised and presented in a straightforward way to facilitate its usage in class. All of them provide a background and the particular ethical aspects on the case to take into account; some of them offer discussion questions and others include specific facts sheets and descriptions of the case that can serve directly as handouts.

Table 3 General content characteristics and value as a teaching tool of the textbooks and manuals on public health ethics. (PH: public health; PHE: public health ethics) 

1 Perceived value by the authors of the article; based on the ethical aspects that are included and whether the book includes cases for discussion and/or other useful content to use in class and/or to prepare lectures.

Articles and cases are predominantly set in the United States, followed by the United Kingdom and Canada (Table 3). Five of them include chapters by international authors and/or covering cases set in other countries. Table 3 also includes an assessment of the overall value as a teaching tool of each of the books as judged by the authors. Almost all were deemed to be of high or good value for teaching PH ethics in MPH, either because the book content is useful as part of the instruction material for students and/or because it is suitable to prepare cases for discussion and debate sessions in class.

Table 4 summarises and categorises the content of the books and manuals into 9 broad areas. All textbooks include an introduction and most of them contain one or more chapters on general aspects of PH ethics. However only five include a specific chapter on frameworks and/or a guide incorporate how to approach ethical reasoning, and only two on the legal aspects of PH and its relationship with ethics. Most areas are included as chapters in all books except for environmental and occupational health (only covered by 6 books), health and social inequities (included in 7; one book deals exclusively with the ethics of social inequalities in health) and PH communication (in 3). The most common areas covered in the books were disease prevention and control (especially issues with vaccination and surveillance), followed by health promotion (in particular, obesity, smoking and alcohol), health policy and resource allocation. Some topics like smoking and HIV are used as examples and cases in several areas.

Table 4 General areas of public health and public health ethics included in the books. (PH: public health; PHE: public health ethics) 

4. Discussion

Ethics in public health is taught in half (7 out of 14) of the existing masters of public health in Spain. In all of these 7 MPH, ethics is taught together with another area of PH (introduction to PH, legal and policy issues in PH, and/or communication of PH) and the subject is mandatory. On the other hand, there is a considerable extent of textbooks of ethics in PH that can be considered of high value for teaching. In this review we identified 12 books, five of them containing or consisting of case studies for discussion.

The scarcity of formal education in PH ethics detected in Spain comes perhaps as no surprise considering the insufficient and inconsistent teaching reported before in the US and in Europe ^4,17. In the US, the country that has progressed most in this area in the last 25 years, things have significantly improved since 1974 when the first survey carried out to assess the extent and nature of instruction in ethics in schools of public health showed that the majority (10 out of 15) did not offer any such instruction ¹⁸. In 1996 another similar survey showed that ethics instruction was required for all MPH students only at 38% of the schools surveyed ¹⁹. A more recent study with similar methodology found that around 72% of schools of public health in the US offered a specific course on this subject, although the response rate was relatively low at 40% ¹⁷.

Regarding the situation in Europe, in 2003 Kessel et al found, after mailing a questionnaire survey on the content of teaching PH teaching in the United Kingdom, that 52% of the institutions providing postgraduate education on PH were teaching PH ethics. In 2010, a survey targeting the 82 members of ASPHER achieved a response rate of 52% of which 38 (95%) of the respondents schools reported that ethics was included in their master programmes ⁸. Given the relatively low response rates of the more recent surveys both in the US and Europe it is reasonable to argue that the overall real percentage of schools teaching ethics could be significantly lower.

This rather meagre picture of the teaching of ethics in PH contrasts with the comprehensive set of published codes and recommendations in public health education that include ethics and proficient ethical practice of PH. In the US, the Public Health Code of Ethics, promulgated by the Public Health Leadership Society and adopted by the American Public Health Association in 2002, describes 12 principles for the ethical behaviours of PH professionals and agencies ²⁰. Its accompanying document, published in 2004, outlines the ethical skills to fulfil this code ²¹. Another 3 documents describe the competencies in PH: the Association for Schools of Public Health (ASPH) Core Competencies were developed among others for MPH students ²²; the Competencies for Applied Epidemiologists in Governmental Public Health Agencies, published by the Centers for Disease and Control and Prevention (CDC) and the Council of State and Territorial Epidemiologists (CSTE) ²³; and the Core Competencies for Public Health Professionals from the Public Health Foundation's council on Linkages between Academia and Public Health Practice (PHF COL) ²⁴. These documents set the expectations that PH professionals should be proficient in, including the areas of professional ethics, research ethics and public health ethics ⁹.

In Europe, ASPHER's European Public Health Core Competences Programme (EPHCCP) consists of the European Core Competences for MPH Education (ECCMPHE) and the European Core Competences for Public Health Professionals (ECCPHP) and both include an independent section on Ethics outlining the intellectual and practical competences expected from PH students and professionals ²⁵. In Spain, in 2006 a set of 11 PH professional competences or activities was published, structured in 3 broad functions and each activity covering different competencies ²⁶. Although specifically mentioned in one competency, i.e. "to assess the ethical aspects of health interventions", all activities include competencies based on core ethical values, such as addressing health and social inequities, taking into account population's opinion and needs, and providing adequate information on health risks and interventions.

All these sets of competencies include clear expectations for proficiency in ethics in public health, yet the inclusion of the pertinent instruction in the PH programmes seems to be far from achieved. Like Simón-Lorda et al conclude in their article, the introduction of PH ethics in the curricula of public health professionals is an evolving process in many regions of the world ¹⁷. In Spain this process seems to be at its dawn and much work remains to be done. Perhaps one step could be to explicitly mention ethical reasoning as a core competency in the MPH curricula, which will aid the development of specific courses on PH ethics as well as the incorporation of ethical aspects across other PH courses.

We might ask ourselves about the reasons of this apparent reluctance to expand and improve the teaching of PH ethics. On the one hand, Callahan and Jennings argue that "teaching ethics is controversial, intellectually difficult, institutionally challenging and expensive" ² and Jennings affirms that "it is perfectly natural to feel uncomfortable with the subject matter of public health ethics and with the special challenges of teaching ethics" and points out several obstacles that facilitators might encounter when leading ethics discussions ²⁷. On the other hand, many PH professionals are civil servants and hence their activity is not embodied within deontological codes but rather governed by a different set of rules and norms, contributing perhaps to their reduced interest and perceived need of an ethical background.

While good curriculum materials and textbooks can't do the work of good teaching, they can certainly facilitate it. With the review and description of relevant textbooks and manuals in PH ethics we hope to contribute to this process. Most of the 12 books reviewed here can help preparing classes, organising ideas and providing case examples for discussion. Some of the chapters and essays in the books could be included as part of the required readings, and the in-depth ethical analysis of relevant PH topics will certainly add perspective and arguments to enhance lectures and discussions.

However, traditional didactic approaches need to be supplemented with additional modalities such as case studies and role playing ⁴. When done effectively, these type of sessions have a lasting effect which is especially necessary given that there might be considerable gaps in time between learning about ethics and being confronted in "real life" to an issue containing ethical considerations. We want our students and PH professional to develop critical reasoning about ethical concepts, otherwise ethical principles and norms just become an additional jargon that practitioners use rather than effective tools for analysis and decision-making ²⁸. The use of cases for discussion facilitates the development of these analytic reasoning skills because they can readily exemplify trade-offs among important values and interests and take seriously initially counter-intuitive positions. Five of the books considered in this review consisted or included cases for discussion more or less "ready-to-use" in class. When preparing this kind of debate sessions it might be useful to refer to the introduction in the on-line accessible textbook "Ethics and public health: model curriculum" which includes a guidance on teaching ethics and some "warnings", and also to Potter's and Tulchinsky's articles on the topic of teaching PH ethics ^4,28.

The matter of how to organise the instruction of PH ethics is not a simple one and this can be observed also in the differences in the structure and topics covered by the textbooks here analysed. Most books agree on organising the ethical aspects around different broad areas of public health like health promotion or infectious diseases. However, Kessel thinks that PH ethics should be developed more in terms of analytical tools rather than in terms of a list of topics ⁷, and Coleman suggests a list of key ethical aspects in PH rather than broad PH areas ²⁹. For the purpose of teaching in MPH it is perhaps best to employ the same structure of topics used in the master itself, i.e. the topics covered by the other subjects, which may facilitate students' learning and application.

Some limitations warrant mention. First, regarding the first objective, we collected information on the MPH Internet sites without confirming with master or school representatives whether the courses and curricula are being taught as described online. Although we have no reason to believe that the data online is inaccurate, validation of the fidelity of course implementation is beyond the scope of this study, as is the assessment of the quality and thoroughness of the teaching. Second, some of the online programmes offer more detail than others, so there is a possibility that some MPH offer some ethical training as part of subjects while not being described online. This would mean that the number and share of masters teaching ethics could be indeed higher that what we describe here.

Regarding the second objective, it is feasible that we might have missed some books on PH ethics relevant for teaching. While we searched using several searching engines and strategies, we did not attempt to carry out a systematic review either. On the other hand, if a book is so difficult to find or so seldom mentioned in articles that we did not find it, one might argue it will most likely not be among the popular teaching books. Last, exploring books useful for teaching PH ethics in Spanish was outside the scope of this study for several reasons. We believe that the advances made in Spanish language in PH ethics are far behind those in English, most certainly due to the fact that United States followed by the United Kingdom are the countries that have progressed and published most in this area. Also, the differences in nature and scope of the publications in PH ethics in Spain would make comparisons with the rest difficult in the first place.

Nonetheless, there are at least two materials on PH ethics published in Spain worth mentioning. First, the already cited booklets on PH ethics from the Ethics working group of the Spanish Society of Public Health and Health Administration and the Victor Grífols y Lucas Foundation, who after organising several workshops published an accompanying booklet ^{11,12,13,14,15}. Second, some of the more recent textbooks on epidemiology and/or public health in Spain include a chapter on ethics in PH _³⁰⁾ and some teaching manuals in bioethics include a chapter on ethics in PH _^31). And third, there are a number of publications on the subject in Spanish journals ^32,33.

On a final note, what we have explored here are formal approaches of teaching ethics in PH, i.e. we have assessed the level and materials of teaching of ethics within the academic settings and through specific courses and textbooks on ethics in public health. However, there are other ways of integrating ethics within the overall training program of public health and ethics instruction which can be done from an informal approach. Informal approaches involve interactions in which there may be no intent for such transfer, but transfer occurs ³⁴. Some people argue that the informal sector is often more important than the formal one in forming the attitudes and opinions of young professionals. Hence, besides the formal ethics teaching, we must not forget the role that ethics plays in the academic environment in general. We need to integrate ethics throughout the training, pay attention to the importance allocated to it by other courses and departments, and set precedent through the attitudes of mentors and advisors as well as through ethical guidelines for student behaviour.

To conclude, with only half of the masters of PH including ethics explicitly on their programmes we can say that training in PH ethics is not yet at the core of public health programmes in Spain and there is room for improvement. On the other hand, the relative abundance and quality of resources suitable for teaching PH ethics should facilitate the task of further integrating the topic in the training of PH professionals. Offering ethics training, including ethical analysis of the PH issues involved, should be part of every PH curriculum both as a dedicated course and as part of other courses. Case studies are a key element for PH ethics education as they inculcate ethical reflection as a habit and serve to illustrate ethical conflicts that most PH professionals will face in the future. With this study, we have aimed to contribute in the evolving process of introducing and expanding PH ethics courses in the curricula of PH professionals in Spain and beyond.