Ethical Aspects in Providing Health for All

Healthcare ethics should be based on the principle of how quality healthcare can be provided to all without sacrificing the basic rights of even the few. The Patient Protection and Affordable Care Act (PPACA) includes reforms such as prohibiting insurers from denying coverage from pre-existing conditions, expanding Medicaid eligibility, subsidizing insurance premiums and providing incentives for businesses to provide health care benefits. The people want four fundamental goals from the healthcare system. First, they want high quality health care which can provide them the best treatment. Then they want the freedom of choice to decide ‘who, when and where’. Third is the affordability. Finally, the fellow citizens should also share in the costs and also benefits of healthcare. There are individual variations in the priorities given to each of these goals [4].


Introduction
Healthcare ethics should be based on the principle of how quality healthcare can be provided to all without sacrificing the basic rights of even the few. The Patient Protection and Affordable Care Act (PPACA) includes reforms such as prohibiting insurers from denying coverage from pre-existing conditions, expanding Medicaid eligibility, subsidizing insurance premiums and providing incentives for businesses to provide health care benefits. The people want four fundamental goals from the healthcare system. First, they want high quality health care which can provide them the best treatment. Then they want the freedom of choice to decide 'who, when and where'. Third is the affordability. Finally, the fellow citizens should also share in the costs and also benefits of healthcare. There are individual variations in the priorities given to each of these goals [4].
The most ethical issue arising in clinical practice is to what is to be given importance: to the people or to profits. If we practice with a business mind only it will lead to abuses of patient dignity.
In a system of for-profit healthcare doctors come under the control of lay managers who are accountable to share holders whose sole aim is to make profit. Such hospitals will encourage doctors to promote profit producing drugs, surgeries, tests and treatments. Some doctors who themselves own the facilities that they operate try to apply their machinery like dialysis units in unwanted situations and also delay kidney transplants to make more profit. Human rights norms and standards are drafted by government representatives who impose legal obligations on the governments that ratify them. So this study is developed to know the various ethical issues that are prevalent in healthcare and to make recommendations which can guide the healthcare workers in such situations.

Aim/Objective
The aim of this study is to assess the application of ethical issues in providing health for all.
The objectives of this study are: a) To find out the important ethical issues faced by the healthcare workers b) To make recommendations this can guide the healthcare workers during their practice taking care of the ethical aspects.

Study Design and Methodology
This is a review of literature study. 15 articles were selected for literature review. The articles were downloaded from the internet using the Google search engine. The keywords used in the search engine were 'ethical aspects in providing health for all'. The articles dealing with the ethical aspects in general health care were only considered for the study. The ethical issues were assessed based on their practicality. The articles were analyzed for the ethical issues involved in health care and providing health for all. The articles were gone through thoroughly and a brief idea of the articles was sketched out in the observation of this study. These observations were used to assess the ethical issues involved in healthcare. Articles dealing with ethical issues in healthcare section were only chosen for the study. All the articles chosen were in English. Articles shown in the first 3-4 pages of the Google search engine were only selected for the study. The article search was done in the month of October to the first week of November 2016. Around 40 articles appeared in the first 4 pages of the search engine. Majority of the articles selected were those which were published in journals.

Health Promotion Ethics
Health promotion ethics is moral deliberation about health promotion and its practice. It is regaining attention over the broader literature on public health issues. Health promotion can be approached as a normative ideal and as a practice. Normative ideal deals with the equity of social arrangements. The two main ethical questions that arise are: What is a good society? b.
What should health promotion contribute to a good society?
Health promotion deals with four main issues: the potential for health promotion to limit or increase the freedom of individuals; health promotion as a source of collective benefit; the possibility that heath promotion strategies might stigmatize those who are at higher risk of disease; importance of distributing the benefits of health promotion fairly. Health promotion ethics should thoughtfully connect social and political philosophy with an applied, empirically informed ethics of practice [1].

Ethical issues in Biobanks
A Biobank is a type of biorepository that stores biological samples (usually human) for use in research. The samples for biobanks come from patients who come for treatment and also from the general public. Thus biobanks play an inevitable role in providing healthcare. It has become an important resource in medical research and also supports contemporary research like genomics and personalized medicine. Biobanks give researchers access to data representing a large number of people. They have provoked questions on privacy, research ethics and medical ethics. Consensus has been reached that operating biobanks without establishing carefully considered governing principles and policies could be detrimental to communities that participate in biobank programs.
Ethical aspects have been focused in the whole bio banking research field. The old and the most typical ethical issues need constant re-appraisal and continuing discussion. Bio banks consist of organized collection of human biological samples used together for biomedical research. Bio banks have been heavily supported by many governments because research results are very important for the society. In the recent few years bio banks have become increasingly complex. This requires constant reappraisal and continuing discussion [2].

Public Health Ethics
Public health ethics has emerged as a bounded area of teaching and research as there is an increase in complexity of the public's health care needs. This article suggests ways to incorporate professionalism into the teaching of public health practice. Ethics language, concepts and tools for decision analysis have to be taught to students for making inevitable ethical choices in their professional practice. As public health ethics awareness increases, the critical link between education and practice will be manifest in professional publications and case studies and also in the professional work of health care practitioners [3]. The various definitions and activities of public health, principles and substantive elements central to public health were discussed in the study "Public Health Ethics" by Erika Blacksher.
One of the definitions of public health says that it is "What we, as a society, do collectively to assure the conditions in which people can be healthy". Another definition says it is "The science and art of preventing disease, prolonging life and promoting health through organized efforts of society". The main functions of public health agencies are assessing community health needs and arranging the resources for responding to them, developing health policy in response to specific community and national health needs, and making sure that conditions contribute to good health, including high quality medical services, safe water supplies, good nutrition, unpolluted atmospheres and environments that offer opportunities for exercise and recreation to be available to individuals. The "social determinants of health" are the conditions in which people grow up, live, work, and play. Public health ethics aims at: a.
Producing benefits, often but not exclusively health benefits, and often interpreted in health policy as a utilitarian commitment to maximizing aggregate health benefits.

b.
Preventing harms, often health harms, such as preventable morbidity and premature death.

c.
Distributing health benefits fairly or distributive justice (fair distribution of social goods).

e.
Respecting individual autonomy and liberty of action.

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f. Respecting and fulfilling universal human rights. g.
Respecting privacy and confidentiality.
h. Protecting non-dominant subgroups from marginalization and stigmatization. i.
The topics dealt in this study "Essentials of Public Health Ethics" by Ruth Gaare Bernheim, James S Childress, Richard J Bonnie and Alan L Melnick are the frame work for public health ethics, the moral norms, addressing ethical conflicts and dilemmas in public health, justificatory conditions for overriding norms in conflict situations, public justification in context, the ethical conflicts, the role of Public Health Code of Ethics, metaphors in public health ethics and the conclusions arrived at [6].

Healthcare and Insurance
The provision of quality healthcare for the many without sacrificing the basic rights of even the few has been an ethical issue of justice. The Patient Protection and Affordable Care Act (PPACA), was first enacted in 2010 and later upheld by the Supreme Court in June 2012 provides some guidance to states, insurers, employers and consumers about what they are required to do by 2014. The act is designed to expand insurance coverage, control costs and target prevention. One of the primary targets is adults aged 19-64 years. The reforms included by PPACA were prohibiting insurers from denying coverage for preexisting conditions, expanding Medicaid eligibility, subsidizing insurance premiums, and providing incentives for businesses to provide health care benefits. All income and age groups are covered at a reduced cost under the act. The PPACA brought about a 6 % drop in the adult death rate for three states. The American public is still sharply divided on the issue of PPACA in spite of these positive anticipated outcomes [4].

Health Economics
Health economics has a key role on policy and valuejudgmental issues that arise as a result of the work of economists. The contributions of the authors of the journal illustrate how economists have approached ethical issues in health service and value their potential as sources of conflict or harmony to the ethical questions that arise in healthcare [7].

The Patient Protection and Affordable Care Act
Healthcare brings to the fore various ethical issues. The Patient Protection and Affordable Care Act (PPACA) of 2010 raise several ethical issues. The basic provisions of PPACA and important ethical issues of healthcare reform, including the moral foundations of reform, the American College of Emergency Physicians (ACEP), Code of Ethics and healthcare reforms, public health, access to care, ED crowding and end of life issues are brought out in this paper. The PPACA also advocates the formation of many bodies like National Prevention, Health Promotion and Public Health Council. According to this, insurance companies will be prohibited from charging deductibles for most preventive care. People who are paying more than 8% of their household incomes for their health insurance would be exempt from the requirement to purchase insurance [8].

Human Rights and Healthcare Ethics
Ethics in healthcare had originated since the time of Hippocrates and is studied in the field of bioethics. The human rights and healthcare ethics go hand in hand in the efforts to improve public health. The ethical principles are formulated in the form of guidelines and proposed codes of conduct. The Helsinki Code of 1964 was the precursor to the field of bioethics which involves research in life sciences as well as ethics of health practice. In the U.S., bioethics of the 1960s and 1970s emphasized the central priority of individual autonomy, reflecting the individualism of American culture rather than the social solidarity of the other cultures. The ethical guidelines can be easily adjusted or drafted to meet evolving scientific and human challenges to allow regional and national variations as necessary. In contrast, human rights norms and standards are drafted by government representatives. The 1948 Universal Declaration of Human Rights designed by American Eleanor Roosevelt contains the principles of many cultures and traditions and what rights should exist.
The International Covenant on Economic, Social, and Cultural Rights tells about "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health" and brings to light associated governmental responsibilities. The responsibilities include reducing infant mortality; improving environmental and industrial health, preventing, treating, and controlling epidemic, endemic, occupational, and other diseases, and ensuring the availability of medical care in the event of sickness. The International Covenant on Civil and Political Rights allows freedom of peaceful assembly and also imposes restrictions necessary for the protection of public health. Other rights include access to goods and services such as information, food, clothing, housing, and safe workplaces, as well as environmental rights to clean water and air. A right to development needs governmental initiatives for protection of public health interests relevant to the environment and for promoting the economic development that generates resources for individual and public health and for environmental protection and enhancement [9].

Worksite Health Promotion
Worksite health promotion involves employers, employees, occupational physicians, insurance companies, providers, labour unions and research and knowledge institutes. Empirical research on ethical considerations of worksite health promotion is rarely done. Occupational health usually means 'being able to perform your job'. The occupational health risk factors involved may be categorised into worksite health promotion; employee-related activities and work-related activities. Responsibility for lifestyle behaviour can be understood by occupational health risk factors and worksite health promotion concepts. Responsibility of employees and employers differ. For employees, it means autonomy, while for employers and other stakeholders, responsibility equals to duty. This creates uncertainty in the relationships between stakeholders in the workplace [10].

The Philosophy of Healthcare
The philosophy of healthcare means the study of the ethics, processes, and people which constitute the maintenance of health for human beings.

Health Technology Assessment
An essential component of health technology assessment is the assessment of ethical aspects. Ethical aspects of health technologies are considered with reference to values or norms in such a way that may be prescriptive, or offer guidance as to how to act or relate to the issue in question. As long as ethical analysis and its conclusions are presented without hiding the facts, disclosing how well founded the conclusions are and/or whether there are alternative conclusions, the HTA agencies should take the ethical analysis to a definite conclusion [11].
Health technology assessment (HTA) is the study of the progress of health technologies. Ethical aspects of health technologies are considered with reference to values or norms in such a way that may be prescriptive, or offer guidance as to how to act or relate to the issue in question. The distinction between assessment and appraisal seems difficult to uphold, unless the scrutiny stops short of a full ethical analysis of the technology. It provides a knowledge base for decision makers in health care technologies. There is no accepted method for analyzing the ethical aspects in health technologies. The EUnetHTA project focuses on the transferability of HTA between countries. Assessment topics, methods and outcome have to be selected. Health technologies have significant impact on people other than the patient. HTA combined with ethical considerations can improve the relevance of technology assessments for health care and health policies in both developed and developing countries [12].

Healthcare for Immigrants
'Do all have a right to healthcare regardless of their citizenship' -this question was discussed in the article 'Ethical inquiry: March 2012'. What if the immigrants are undocumented? Who should pay for them? What if they are the same persons whom they tried to keep out of their territory? Some claimed that undocumented immigrants have no claim to health benefits since they don't have any legal rights in the country. The medical practices have to be overextended in order to provide healthcare for undocumented immigrants. Pelner also argued that undocumented immigrants bring dangerous diseases that were not present in the United States increasing the hospital expenses. Further it creates burden on taxpaying citizens in the country. Those who argued for providing healthcare to undocumented immigrants stated healthcare as a human right. Another belief was that undocumented immigration should be considered separate from healthcare policy. Some also stated that it is discriminatory and dehumanizing to deny healthcare for undocumented immigrants. They also argued that undocumented immigrants are contributing members of society [13].

Law and Ethics
Law and ethics along with public health sciences guide us throughout the practise of public health. Scholars and practitioners in the field of law and ethics have focussed mainly on medical care. The theory of practise of public health is guided by law and ethics along with public health sciences [14].

Profit motive in Healthcare
This article brings out the profit motive in the field of health care. There has been an instance in the US when people were shifted from private hospitals to county facilities not for medical reasons but for economic ones. Otherwise, these patients simply weren't "good business". In this context the lines from the Hippocratic Oath needs to be remembered "I solemnly pledge to consecrate my life to the service of humanity; the health of my patient will be my first consideration" [15].

Discussion
For the practice of health for all in an ethical manner, good research and considerate decisions about medical treatments have to be made. The patient's opinion about his own health has to be considered. The goal of an ethics committee is to establish a written code of ethics that details the policies and

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procedures that determine proper conduct of all employees. The growing gap between the rich and the poor makes it difficult for the professionals to decide what the right thing is that can be done for public health. Professionalism is one interdisciplinary competency for graduate education in public health. Healthcare ethics should make sure that quality healthcare is provided to all without sacrificing the basic rights of even the few. People expect mainly four things from the healthcare system: i.
High quality healthcare ii.
Freedom of choice to decide on their treatment iii. Affordable treatment iv. The fellow citizens should also share in the costs and also benefits of healthcare.
Health promotion ethics is moral deliberation about health promotion and its practice. The two main ethical issues in health care systems is a.
What is a good society b.
What should health promotion contribute to a good society? Ethical aspects of the biobanking research system were discussed. Biobanks have organised system for collecting human biological samples used together for biomedical research. In the recent years biobanks have become increasingly complex. Professionalism has to be incorporated in the treatment of public heath practise. Students have to be taught how to make inevitable ethical choices in their professional practice.

The Patient Protection and Affordable Care Act
Provides some guidance to states, insurers, employers and consumers. The act was made to expand insurance coverage, control costs and target prevention. The act also prohibited insurers from denying coverage for preexisting conditions, expand Medicaid eligibility, subsidize insurance premiums, and provide incentives for businesses to provide health care benefits.
The PPACA brought about a 6% drop in the adult death rate for three states in the US. The Patient Protection and Affordable Care Act also advocate the formation of many bodies like National Prevention, Health Promotion and Public Health Council. According to this, insurance companies will be prohibited from charging deductibles for most preventive care. People who are paying more than 8% of their household incomes for their health insurance would be exempt from purchasing insurance. There is no such equivalent act in the Indian setting for getting reasonable level of healthcare for poor patients. The BPL cards and the health welfare schemes are showing some promise but their overall effectiveness needs to be studied.
Ethics is studied in the field of Bioethics and originated since the time of Hippocrates. The ethical principles of healthcare are formulated in the form of guidelines and proposed codes of conduct. The Helsinki Code of 1964 describes about research in life sciences as well as ethics of health practice. Bioethics of 1960s and 1970s in the United States emphasized the central priority of individual autonomy. The guidelines have to be adjusted according to evolving scientific and human challenges to allow regional and national variations as necessary.
Human rights norms and standards are drafted by government representatives. The 1948 Universal Declaration of Human Rights explains about what rights should exist. Everyone has a right to obtain highest attainable standard of physical and mental health. Associated government responsibilities include reducing infant mortality; improving environmental and industrial health, preventing, treating, and controlling epidemic, endemic, occupational, and other diseases, and ensuring the availability of medical care in the event of sickness. The International Covenant on Civil and Political Rights permits peaceful assembly and also imposes restrictions necessary for the protection of public health. Other rights include access to goods and services such as information, food, clothing, housing, and safe workplaces, as well as environmental rights to clean water and air. Responsibility of employees and employers differ which creates uncertainty in the relationships between stakeholders in the workplace. Public health can be defined as "What we, as a society, do collectively to assure the conditions in which people can be healthy". It can also be defined as "The science and art of preventing disease, prolonging life and promoting health through organized efforts of society". Public health aims in assessing community health needs and arranging the resources for responding to them, developing health policy in response to specific community and national health needs, and making sure that conditions contribute to good health, including high quality medical services, safe water supplies, good nutrition, unpolluted atmospheres and environments that offer opportunities for exercise and recreation to be available to individuals. The "social determinants of health" are the conditions in which people grow up, live, work, and play.
Can healthcare be provided to undocumented immigrants? Some claimed that undocumented immigrants have no claim to health benefits since they don't have any legal rights in the country. The medical practices have to be overextended in order to provide healthcare for undocumented immigrants. It was also argued that undocumented immigrants bring dangerous diseases that were not present in the United States increasing the hospital expenses. Further it creates burden on taxpaying citizens in the country. But some were of the opinion that undocumented immigrants should be provided healthcare since healthcare is a human right. Some also believed that it is discriminatory and dehumanizing to deny healthcare for undocumented immigrants and they are contributing members of society.
Health technology assessment is the study of the progress of health technologies. A cochlear implant for children is an example where there are conflicting values. Cochlear implants can be a remedy of a medical condition (deafness) or a threat against the Sign Language as a natural language in the deaf community. Health technologies have significant impact on people other than the patient. Health technology assessment has to be combined with ethical considerations to improve the relevance of technology assessments for health care and health policies in both developed and developing countries. Scholars and practitioners in the field of law and ethics have focussed mainly on medical care.
Health economics has a key role on policy and valuejudgmental issues that arise as a result of the work of economists. There have been instances in the US when people were shifted from private hospitals to county facilities not for medical reasons but for economic ones. Hippocratic Oath which says "I solemnly pledge to consecrate my life to the service of humanity; the health of my patient will be my first consideration" has to be considered in this context. Similarly in India it is common to see patients giving up good care and move home against medical advice when the resources have dried up. These patients could have had a total recovery if the finance /insurance backed them. Only about 10% of Indian population have a health insurance policy.

Conclusion and Summary
Considerate decisions about medical treatment and research is required for the practice of health for all in an ethical manner. The patient should be given freedom to choose his method of treatment. The help of an ethics committee can be made use of to establish a written code of ethics that details the policies and procedures that determine proper conduct of all employees.
Public health policies have to be made keeping in mind the growing gap between the rich and the poor. Healthcare should be provided to all without sacrificing the rights of anyone.
Biobanks should try to adapt to the broader recommendations of guidelines which are internationally accepted for human subject research and use changing guidelines as they become accepted. Professionalism has to be maintained in the public health practice. Students in the healthcare sector have to be taught how to make inevitable ethical choices in their professional practice. Acts like the Patient Protection and Affordable Care Act has to be made to expand insurance coverage, control costs and target prevention. Health insurance should be provided free of cost for all taxpayers.
The guidelines for ethical practice of healthcare have to be adjusted according to evolving scientific and human challenges to allow regional and national variations as necessary. Government has to take adequate steps to reduce infant mortality; improve environmental and industrial health, prevent, treat, and control epidemic, endemic, occupational, and other diseases, and ensuring the availability of medical care in the event of sickness. Rights of a citizen include permission to peaceful assembly and also restrictions necessary for the protection of public health, access to goods and services such as information, food, clothing, housing, and safe workplaces, as well as environmental rights to clean water and air. For employees responsibility is autonomy and for employers it is the duty. Public health agencies should be able to assess community health needs and arrange the resources for responding to them, develop health policy in response to specific community and national health needs, and make sure that conditions contribute to good health, including high quality medical services, safe water supplies, good nutrition, unpolluted atmospheres and environments that offer opportunities for exercise and recreation to be available to individuals. It will be discriminatory and dehumanizing to deny healthcare for undocumented immigrants.
Health technology assessment (HTA) has to be combined with ethical considerations to improve the relevance of technology assessments for health care and health policies in both developed and developing countries. It is also an unethical practice to shift from private hospitals to county facilities not for medical reasons but for economic ones. A healthcare practitioner has keep in mind the Hippocratic Oath in every context which says "I solemnly pledge to consecrate my life to the service of humanity; the health of my patient will be my first consideration."

Recommendations
Recommendations for healthcare workers to practice in an ethical manner:

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a) Physicians should be encouraged to involve patients and their representatives in shared decision making.
b) The concept of autonomy in the Indian context is more flexible and accommodating than the western model. Thus while respecting individual autonomy, physicians should also engage with care giving in the community. c) Provision of best quality health care at affordable costs and delivered in an ethical manner is not only the responsibility of the state, but also of each individual doctor.