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Case Information<\/p>\n
\u201cIt\u2019s going to be a great day!\u201d thought Joe Ascot, director of environmental services<\/p>\n
for Peace County Health Department. Even though he struggled with having too few<\/p>\n
restaurant inspectors for the restaurants in his growing county, Joe knew that public<\/p>\n
health workers always soldier on and get things done. Then, the telephone rang.<\/p>\n
The caller was the Director of Emergency Services at Peace County Hospital.<\/p>\n
He said that his emergency department (ED) waiting room was full of vomiting patients.<\/p>\n
He suspected that Salmonella poisoning was the reason for this ED rush. The most<\/p>\n
severe symptoms occurred in eight children under the age of 5 and five women older<\/p>\n
than the age of 70. Two of the children were in a serious condition. The ED nurses<\/p>\n
were able to determine that the patients had all attended the Grandma and Princess<\/p>\n
Luncheon at Aunt Tandy\u2019s Restaurant in Peace City. This catered event featured a menu<\/p>\n
of a fruit cup, chicken divan, French mashed potatoes, and green beans. For dessert,<\/p>\n
there was Aunt Tandy\u2019s chocolate cake and ice cream.<\/p>\n
The ED director asked Joe to contact the Centers for Disease Control and<\/p>\n
Prevention (CDC) immediately and check his records for inspection reports on Aunt<\/p>\n
Tandy\u2019s Restaurant. Joe was surprised about what appeared to be Salmonella poisoning.<\/p>\n
He knew that poor kitchen hygiene was one of the sources of this problem, but he<\/p>\n
was certain that Aunt Tandy\u2019s was not to blame. After all, the restaurant had a great<\/p>\n
reputation in Peace County.<\/p>\n
Before Joe called the CDC to report a possible outbreak of Salmonella<\/p>\n
poisoning, he searched his inspection database. \u201cThere\u2019s nothing here!\u201d he thought<\/p>\n
as he searched and rechecked the database. There was no record of any inspection<\/p>\n
of Aunt Tandy\u2019s Restaurant during the past 6 months or even within the past<\/p>\n
year. Immediately, he telephoned his restaurant inspectors. None had a record of<\/p>\n
inspections for Aunt Tandy\u2019s on their lists.<\/p>\n
\u201cWhat should I do now? There is no documentation for an inspection at Aunt<\/p>\n
Tandy\u2019s, and I have to call the CDC. Will I lose my job?\u201d thought Joe. With great anxiety,<\/p>\n
he picked up the telephone and followed the specified protocol. He dialed the number<\/p>\n
for the state health department, which would then contact the CDC.<\/p>\n
Note: The state health department, working in cooperation with the CDC,<\/p>\n
conducted an investigation of Aunt Tandy\u2019s restaurant based on the data from the<\/p>\n
patient reports. Investigators found that Aunt Tandy assigned a new employee for food<\/p>\n
preparation. This employee cut up the raw chicken for the chicken divan, then wiped<\/p>\n
the board with a dishcloth and cut up the fruit for the fruit cup. This error allowed<\/p>\n
transfer of the Salmonella bacteria from the uncooked chicken to the fruit. Those who<\/p>\n
were most susceptible (children and the elderly) had the worst symptoms.<\/p>\n
Commentary on the Case<\/p>\n
What ethics issues did Joe have before the Salmonella surprise?<\/p>\n
Think about the situation that Joe faced before the telephone call. He knew that he did<\/p>\n
not have enough staff, which meant heavy caseloads. There was a high probability that<\/p>\n
inspectors did not spend enough time in each of their restaurants. The lack of staffing<\/p>\n
also increased the likelihood that there would be a failure in the system and potential<\/p>\n
health problems for the community.<\/p>\n
(continues)<\/p>\n
Summary 229<\/p>\n
Joe insisted that the Peace County Health Department hire more restaurant<\/p>\n
inspectors and presented his rationale to the director. However, the director used<\/p>\n
utilitarian ethics. For example, he weighed the community benefit of hiring more<\/p>\n
restaurant inspectors against the benefit of hiring more public health nurses. Given<\/p>\n
a limited budget, he chose to hire those who provided the greatest benefit to the<\/p>\n
community. Therefore, the director favored hiring nurses over restaurant inspectors.<\/p>\n
Joe was counting on the ethics of restaurant owners to be concerned with<\/p>\n
nonmaleficence and justice for their patrons. Because it was in their best interest, he<\/p>\n
assumed that they would meet public health standards and keep the kitchen sanitation<\/p>\n
up to code. After all, it was in their self-interest to make sure that a negative health<\/p>\n
event did not happen.<\/p>\n
What were the ethics principles violations in this case?<\/p>\n
To answer this question, consider the factors that contributed to this situation. The<\/p>\n
restaurant owner, the employee in charge of the preparation, restaurant inspectors,<\/p>\n
and Joe all violated ethics principles in different ways. In examining these violations,<\/p>\n
one can see how things that appear to be unimportant can lead to serious healthcare<\/p>\n
consequences.<\/p>\n
Begin with the principle of staff justice. Aunt Tandy did not provide the<\/p>\n
new employee with adequate training about kitchen sanitation and correct food<\/p>\n
preparation. Perhaps Aunt Tandy assumed that he knew not to prepare raw chicken on<\/p>\n
the same cutting surface as fruits and vegetables. Perhaps she also did not take time to<\/p>\n
train this newly hired employee. Whatever the reason, Aunt Tandy placed the employee<\/p>\n
in a disadvantaged position. He was not trained but was accountable for the outcomes<\/p>\n
of his actions. Certainly, this employee contributed in a major way to the Salmonella<\/p>\n
poisoning outbreak, but was he solely to blame?<\/p>\n
Aunt Tandy also contributed to the harm. Her lack of due diligence in protecting<\/p>\n
the public through training and engagement in food preparation led to her serving<\/p>\n
contaminated food to her customers. Although she did not intend to cause harm, her<\/p>\n
decisions contributed to this harmful event. In addition, the reputation of Aunt Tandy\u2019s<\/p>\n
restaurant could suffer. Negative publicity from the Salmonella surprise could cause<\/p>\n
Peace County residents to choose other restaurants. Her potential lack of business could<\/p>\n
lead to staff layoffs or even the closing of this once well-respected restaurant.<\/p>\n
Look at the actions of the food preparation employee. Certainly, his actions<\/p>\n
violated the principle of nonmaleficence. Perhaps he was in a rush and took the<\/p>\n
shortcut to speed up his preparation. Maybe he actually thought that wiping the<\/p>\n
cutting board with a towel would make it sanitary. Whatever the reason for his actions,<\/p>\n
he was a major contributor to the Salmonella outbreak and the harm to the children<\/p>\n
and their grandmothers.<\/p>\n
The food preparation employee also violated the intent of the principle of justice.<\/p>\n
His actions did not demonstrate fairness to the customers, who relied on his integrity<\/p>\n
to produce safe food. In addition, he was not fair to his fellow employees because his<\/p>\n
actions caused harm to their collective reputation and to their potential livelihood.<\/p>\n
Assume that this employee had no negative intent; he was careless and did not think<\/p>\n
beyond the moment. Aristotle\u2019s practical wisdom should have been present. Had he<\/p>\n
thought about the potential consequence of his decision, the Salmonella poisoning<\/p>\n
would not have occurred.<\/p>\n
What about the inspectors and their violation of ethics principles? First, the principle<\/p>\n
of autonomy for Aunt Tandy was honored because they assumed that she was following<\/p>\n
A CASE FOR ETHICS (continued)<\/p>\n
230 Chapter 13 Public Health and Ethics<\/p>\n
correct food protection protocols. Therefore, they also assumed that the restaurant was up<\/p>\n
to code and did not inspect her business. In their defense, with their busy schedules and<\/p>\n
their knowledge of Aunt Tandy\u2019s positive reputation, they may have decided to use their<\/p>\n
limited resources to inspect restaurants with a less stellar reputation. This action might be<\/p>\n
a form of utilitarianism, but their assumptions led to a failure to protect the public. With<\/p>\n
this decision, the inspectors also violated the principle of justice. Treating Aunt Tandy\u2019s<\/p>\n
restaurant differently meant that they did not provide fair treatment to all.<\/p>\n
What about Joe? In this case, he violated several ethics principles. Joe had the<\/p>\n
authority to supervise the staff in his department and meet the goals of the Peace<\/p>\n
County Health Department. This authority allowed him autonomy over his actions and<\/p>\n
those of his staff. However, Joe did not use his autonomy appropriately. For example,<\/p>\n
when he checked his database, he could not find any record of an inspection for Aunt<\/p>\n
Tandy\u2019s Restaurant. This omission demonstrated a lack of responsibility on his part, as he<\/p>\n
should have checked the system frequently.<\/p>\n
In addition, Joe contributed to violations of justice. For example, he did not review<\/p>\n
which restaurants his inspectors were evaluating. Had he done that, he would have<\/p>\n
seen that Aunt Tandy\u2019s restaurant was not on their lists. Given this information, he could<\/p>\n
have followed up to make sure that all restaurants were treated fairly. Even though Joe<\/p>\n
was not directly responsible for the actions of the restaurant preparation employee, the<\/p>\n
owner of Aunt Tandy\u2019s Restaurant, or his inspectors, he held a position of responsibility<\/p>\n
for the safety of all restaurants in Peace County. Therefore, his actions violated the<\/p>\n
principle of nonmaleficence. His actions not only contributed to the patients\u2019 harm, but<\/p>\n
also potentially harmed the community and its reputation.<\/p>\n
Should Joe lose his job?<\/p>\n
The answer to this question relates to the policies and procedures for Peace County<\/p>\n
Health Department. In all likelihood, the Health Department director will hold<\/p>\n
someone accountable for the Salmonella poisoning outbreak. Even though Joe was<\/p>\n
facing staffing shortages and had many other problems in his department, he had the<\/p>\n
authority and autonomy to make decisions for the safety of restaurants in the county.<\/p>\n
Joe might consider it unjust, but it is likely that he will lose his job because of the<\/p>\n
Salmonella surprise.<\/p>\n
The Case of Pox on a Plane<\/p>\n
Case Information<\/p>\n
Flight 1414 was 1 hour away from its destination of Newark. It was a 7-hour flight<\/p>\n
from London; flight attendants Cindy, Mari, Eva, and Jason were tired and ready to<\/p>\n
land. \u201cNo one wants to land more than those kids and their sponsors in second class,\u201d<\/p>\n
thought Mari as she approached the back of the plane. She knew that these high<\/p>\n
school students and their three adult sponsors were returning from a missionary trip to<\/p>\n
Gambia, Africa. When she reached the missionary group section, one of the sponsors,<\/p>\n
Mrs. Stanley, stopped her.<\/p>\n
\u201cStewardess,\u201d said Mrs. Stanley, \u201cI am worried about Patti, LaDonna, and Fred.<\/p>\n
They are feverish and sweaty. Look at their arms; they have a rash that looks all bumpy.<\/p>\n
Can you help them? I am afraid that they have monkeypox.\u201d Mari went to the galley<\/p>\n
and brought the students water and a snack. Then she remembered her training on<\/p>\n
prevention of contagious diseases. Could this be smallpox? What was her responsibility<\/p>\n
in this situation?<\/p>\n
Mari went to alert the captain. She explained that the missionary group was<\/p>\n
returning from a trip to Gambia, Africa. From her training, Mari knew that Gambia was a<\/p>\n
(continues)<\/p>\n
Summary 231<\/p>\n
source of cases of monkeypox, a disease that is similar to smallpox. Although smallpox<\/p>\n
vaccinations protect most people from this disease, monkeypox was contagious and<\/p>\n
could spread to the passengers. It also looked a lot like smallpox. \u201cWhat should we do?\u201d<\/p>\n
she asked.<\/p>\n
The captain had also received training on controlling contagious diseases<\/p>\n
and immediately contacted the airport. The authorities at Newark airport took the<\/p>\n
report seriously and contacted the CDC. Within a few minutes, the captain received<\/p>\n
instructions to prevent all passengers from leaving the plane after it landed. The CDC<\/p>\n
quarantined all passengers and staff until they investigated and ruled out smallpox.<\/p>\n
Because she knew that these passengers were going to be very unhappy, the captain<\/p>\n
made the announcement about this process. She apologized for the inconvenience on<\/p>\n
behalf of the airline and explained what would happen as accurately as she could.<\/p>\n
Cindy, Mari, Eva, and Jason worked to calm the passengers and assure them that<\/p>\n
they would be able to leave the plane as soon as possible. They explained that the<\/p>\n
quarantine was to protect everyone. However, several passengers in the first-class cabin<\/p>\n
complained that they had important things to do and that the airline could not hold<\/p>\n
them against their will. They had rights! Some of the passengers demanded to talk with<\/p>\n
the captain and the airport authorities about this matter. Cindy, Mari, Eva, and Jason used<\/p>\n
patience and respect while explaining the necessary actions. They also asked the captain<\/p>\n
to confirm that arrangements would be made for passengers who had continuing flights.<\/p>\n
Imagine the surprise when the Flight 1414 passengers saw vehicles from the<\/p>\n
Newark Emergency Medical Services, Newark Fire Department, and Newark Health<\/p>\n
Department, and the CDC rolling onto the tarmac. The CDC and Newark Health<\/p>\n
Department staff went to the back of the plane to evaluate Patti, LaDonna, and Fred and<\/p>\n
question the rest of the students and their sponsors. Using their iPads, the investigators<\/p>\n
took pictures of the rash and sent them to the CDC. In about 30 minutes, they received<\/p>\n
confirmation that the three students had monkeypox, not smallpox. They could lift the<\/p>\n
quarantine for the rest of the passengers. However, they needed to advise all members<\/p>\n
of the missionary group and those who were seated around them to get immediate<\/p>\n
medical care.<\/p>\n
Before allowing the passengers to deplane, the Health Department staff<\/p>\n
member informed all of the passengers about the situation. If not vaccinated against<\/p>\n
smallpox, they needed to seek medical help. Even though they were not at great risk<\/p>\n
of monkeypox, the Health Department staff advised that passengers practice healthy<\/p>\n
habits. As a precaution, the airline would collect detailed contact information for each<\/p>\n
passenger. Most of the passengers were greatly relieved to be ending their journey.<\/p>\n
However, many in the first-class section threatened to sue. As for Cindy, Mari, Eva, and<\/p>\n
Jason, they would never forget this flight.<\/p>\n
Commentary on the Case<\/p>\n
What ethical principles did Mari and the captain demonstrate?<\/p>\n
First, Mari used her autonomy and training to make the best decision given the<\/p>\n
information that she had available. She knew that monkeypox was not as severe as<\/p>\n
smallpox. However, she also understood that the diseases presented similar symptoms<\/p>\n
and that there was a need to differentiate one from the other. Therefore, she felt a duty to<\/p>\n
protect the passengers on the plane and the community itself by reporting the incident.<\/p>\n
A CASE FOR ETHICS (continued)<\/p>\n
232 Chapter 13 Public Health and Ethics<\/p>\n
In addition, Mari, along with the other flight attendants, used the principle of<\/p>\n
beneficence when dealing with the missionary group and the passengers on the plane.<\/p>\n
The flight attendants tried to make all of the passengers as comfortable as possible. Mari<\/p>\n
answered their questions with accurate information and provided justification for the<\/p>\n
quarantine. In addition, she asked the captain to check with the airline regarding flights<\/p>\n
for passengers with continuing travel plans.<\/p>\n
The captain used the autonomy of her position to make a decision. She had to<\/p>\n
weigh many factors in doing so. For example, there was a chance that she could lose<\/p>\n
her job if her decision was determined to be inappropriate by the airline. She also<\/p>\n
knew that there was a potential for a high number of complaints from inconvenienced<\/p>\n
passengers. However, she trusted Mari\u2019s judgment and training. Therefore, she made the<\/p>\n
call to Newark authorities, which led to the CDC order of the quarantine.<\/p>\n
The captain also practiced nonmaleficence and beneficence in her decision.<\/p>\n
In taking this action, she prevented what could have been an outbreak of a serious<\/p>\n
disease. Even though the affected passengers\u2019 condition was determined to be<\/p>\n
monkeypox and not smallpox, she was instrumental in making sure that passengers<\/p>\n
on the plane received correct information about prevention and treatment. In doing<\/p>\n
so, the captain decreased potential harm to passengers. Likewise, her treatment of the<\/p>\n
situation exhibited beneficence. The captain fully informed the passengers about the<\/p>\n
need for the quarantine and explained the procedures as she knew them. In addition,<\/p>\n
she apologized on behalf of the airline and assured the passengers that the airline<\/p>\n
would make every effort to accommodate their needs. Providing this information<\/p>\n
demonstrated kindness as well as good business sense.<\/p>\n
Why did the airline choose to notify the CDC before the plane landed?<\/p>\n
The airline had to consider its duty to the passengers and to the city of Newark itself.<\/p>\n
To ensure the health and safety of the passengers, the CDC and the Newark Health<\/p>\n
Department had to confirm that the passengers were suffering from monkeypox and<\/p>\n
not smallpox. In addition, they had to protect the city of Newark from exposure to<\/p>\n
smallpox, if it was present. In making the decision to call the CDC, the airline took risks.<\/p>\n
The publicity generated by the incident could produce benefit or harm to the company<\/p>\n
depending on how people viewed it. For example, the public could consider the airline<\/p>\n
a hero because it made a decision to protect both the passengers and the city of<\/p>\n
Newark. Alternatively, it might view the airline as being hyper-reactive to a situation that<\/p>\n
meant nothing. If this were the case, there could be a reduction of credibility and ticket<\/p>\n
purchases. Despite the risks, the airline decided that the most ethical decision would be<\/p>\n
to contact the CDC and risk the consequences of doing so.<\/p>\n
Which ethical position did the passengers in the first-class cabin demonstrate?<\/p>\n
Some of the passengers in the first-class section put their needs above others and<\/p>\n
lacked beneficence and justice. They believed that they were more important than<\/p>\n
other people on the plane are and did not demonstrate compassion or patience. These<\/p>\n
passengers also felt that their rights included protection from inconvenience even<\/p>\n
if their inconvenience protected others from exposure to disease. They did not base<\/p>\n
their ethics decisions on duty toward others or on the greatest benefit for the greatest<\/p>\n
number. Instead, they only thought about themselves and demanded action that<\/p>\n
benefited them as individuals. They also planned to voice their displeasure by writing<\/p>\n
complaint letters to the airline, the CDC, and the Newark Health Department and by<\/p>\n
calling their lawyers.<\/p>\n