DNP 711 - Week 3:
INTRODUCTION/OVERVIEW: The Impact of Healthcare Policy on Health & The Role of Ethics in Decision-Making for Technology/Social Media Use & Self-Harm/Suicidal Behaviors in Arizona’s Emerging Adult Population
Understanding the connection between prevention efforts and healthcare policy requires a brief historical review of suicide in the United States. Suicide is the tenth leading cause of death in the U.S., contributing to more than 40,000 deaths and almost 500,000 emergency department (ED) visits due to intentional self-injury annually (Hogan & Grumet, 2016). American suicide research began primarily in the first half of the 20th-century spurred by the work of Emile Durkheim (2006 [1897]) and focused on a few core tenets of sociological thought about social integration, isolation, cohesion, and support (Wray et al., 2011; Trout, 1980; Kawachi & Kennedy, 1997; and Berkman et al., 2000). Arguably, Durkheim or other branches of sociological theory are the underlying philosophical assumptions of many studies (Wray et al., 2011). These assumptions are essential because of how they also connect to public healthcare policy in that the definition, enforcement structures, and institutional bodies that oversee public policy are sociological functions or elements. For instance, a widely-accepted definition of public policy is "the authoritative decisions made in the legislative, executive, and judicial branches of government that intend to direct or influence the actions, behaviors, or decisions of others" (Longest, 2010, p. 5).
While remaining an element or function of sociology, public policy intersects with technological advancement (such as social media platforms and other mobile digital uses) mainly because of social adaptation and the diffusion of innovation theories (Rogers, 1995 [1962]; Kahle, 1984, 1996). Today, technological advancement and our addiction to it is a driving force of the ever-increasing pace of change globally where cultural and geopolitical shifts follow in its wake (Jehel et al., 2016). The relationship between suicide and technological advancement also remains mixed because of both positive associations to harmful factors resulting in suicide-related outcomes and negative associations to protective factors of suicide prevention efforts. Some examples of positively-associated harmful factors are suicidal normalization, cyberbullying, source of contagion, informational access to encouragement/aid in committing suicide, triggering and competition (social comparison) between users, and workplace automation resulting in human workforce replacement (Marchant et al., 2017; Jehel et al., 2016). Examples of negatively-associated protective factors are increases in access to suicide prevention resources, intervention delivery, crisis support, social isolation reduction, and social connectivity or communication to others (Marchant et al., 2017; Jehel et al., 2016).
SUICIDE PREVENTION POLICY & EFFORTS IN THE UNITED STATES
The first national suicide prevention strategy, released in 2001, emphasized public health measures such as increasing awareness, reducing access to lethal means, providing better access to mental health care services, and stigma reduction of seeking such care or treatment (Hogan & Grumet, 2016). Another effort would later expand those initial suicide prevention efforts, such as the Garret Lee Smith Memorial Act of 2004, which created a grant program for youth suicide prevention funded by the Substance Abuse and Mental Health Services Administration (SAMHSA)(Hogan & Grumet, 2016). Other national efforts established a technical assistance center and crisis call system, also both funded by the SAMHSA. In 2007, the Department of Veteran Affairs established suicide protocols for its facilities and continuous support for a national crisis hotline (Hogan & Grumet, 2016).
SUICIDE PREVENTION POLICY & EFFORTS IN ARIZONA
The White Mountain Apache Tribe, using the Garret Lee Smith Act, created a unique community surveillance system to track and triage suicide deaths, attempts, and ideation that was able to distinguish their tribe's suicide-related rates from others reported by the Indian Health Service (IHS) and the Centers for Disease Control and Prevention (CDC)(Cwik et al., 2016). In 2019, the Arizona State Legislature passed, and Governor Doug Ducey signed the Mitch Warnock Act (SB 1468), which expands suicide awareness and prevention training in Arizona's public schools (Office of the Arizona Governor, 2019). While the possible outcomes of the Mitch Warnock Act are unknown, the White Mountain Apache Surveillance and Prevention System is achieving substantial results that could provide a critical foundational role for future prevention programming and evaluation efforts (Cwik et al., 2016). However, one question that remains unanswered is whether such a tribally-mandated or other government-supported surveillance system is ethically justifiable?
ETHICS & THE AGE OF SURVEILLANCE IN HEALTHCARE SERVICE DELIVERY
In 2005, the WHO established international health regulations (IHR) for surveillance activities offering a multilateral framework for surveillance, notification, and responses to disease outbreaks and other emergencies with potential international public health implications (Velasco et al., 2014). However, the regulations are unclear about data ownership within such surveillance systems, who decides how data usage occurs and to what extent, who decides the identities and qualifications of those decision-makers, and the temporal bounds of data collection, retention, and dissemination. It also leaves murky at best the potential consequences of what happens after surveillance occurs or the cascade of unintended outcomes that may arise thereafter. Nearly a decade later, in 2017, the WHO issued the first international ethics guidelines on public health surveillance, which helps to fill in some of these knowledge gaps but fails to address many other core concerns that an informed citizenry might deem unreasonable (Fairchild et al., 2017; WHO, 2017). The WHO Guidelines for Ethics in Public Health Surveillance only represent a starting point for the sustained discussions that surveillance demands and remains central to the justification of the core activities that surveillance extends beyond the contextual confines of its initial intentions or objectives (Fairchild et al., 2017).
The emergence of multiple forms of unprecedented uses of available health information from both online and real-world sources for assessing the health behaviors of individuals which presents enormous potential for both risks of harm and laudable cures or benefits (Vayena et al., 2012). There are decades of evidence as to the role that public health law and policy (including public health surveillance) play in improving societal health (Chriqui et al., 2011; Thacker et al., 1994, 1989). While law and policy are critical public health tools, essential is our need to remember that tools may be neutral human-created objects that humans choose how to operate or use intentionally for both good and evil purposes (Fairchild et al., 2017; Chriqui et al., 2011).
The possibilities for public health surveillance for suicide prevention efforts or other public health crises are both limitless and contain positive and negative risks or probable outcomes. For instance, surveillance can help create accountable institutions by providing information about health and its determinants and an evidentiary basis for establishing and evaluating public health policy or social organization responses (Fairchild et al., 2017). However, it is crucial that we, as a society, are also able to recognize the "inflection points" that lay before such possibilities and can make well-informed decisions about potential directions for humanity to proceed thereafter (Wallach, 2015). Perhaps, Professor Shoshana Zuboff (2019) best states our present position in the reality of human existence and experience by saying that:
What is at stake here is the human expectation of sovereignty over one’s own life and authorship of one’s own experience. What is at stake is the inward experience from which we form the will to [exercise the strength of individual character] and the public spaces to act on that will. What is at stake is the dominant principle of social ordering in an information civilization and our rights as individuals and societies to answer the questions Who knows? Who decides? Who decides who decides? That surveillance capitalism has usurped so many of our rights in these domains is a scandalous abuse of digital capabilities and their once-grand promise to democratize knowledge and meet our thwarted needs for [an] effective life. Let there be a digital future, but let it be a human future first.
References
Berkman LF, Glass T, Brissette I, Seeman TE. 2000. From social integration to health: Durkheim in the new millennium. Soc. Sci. Med. 51:843–57.
Chriqui, J. F., O'Connor, J. C., & Chaloupka, F. J. (2011). What gets measured, gets changed: evaluating law and policy for maximum impact. The Journal of Law, Medicine & Ethics, 39(1_suppl), 21-26.
Cwik, M. F., Tingey, L., Maschino, A., Goklish, N., Larzelere-Hinton, F., Walkup, J., & Barlow, A. (2016). Decreases in suicide deaths and attempts linked to the White Mountain Apache suicide surveillance and prevention system, 2001–2012. American journal of public health, 106(12), 2183-2189.
Longest, B. B. (2010). Health policymaking in the United States (5th ed.). Chicago, Illinois: Health Administration Press.
Fairchild, A. L., Haghdoost, A. A., Bayer, R., Selgelid, M. J., Dawson, A., Saxena, A., & Reis, A. (2017). Ethics of public health surveillance: new guidelines. The Lancet Public Health, 2(8), e348-e349.
Hogan, M. F., & Grumet, J. G. (2016). Suicide prevention: an emerging priority for health care. Health Affairs, 35(6), 1084-1090.
Jehel, L., Arnal, R., Carmelo, D., & Howard, N. (2016). Suicidal Crisis in the Digital Age. In Understanding Suicide (pp. 63-73). Switzerland: Springer International Publishing AG.
Kahle, L. R. (1984). Attitudes and social adaptation: A person-situation interaction approach (Vol. 8). New York: Simon & Schuster.
Kahle, L. R. (1996). Social Values and Consumer Behavior: Research From the. In The Psychology of Values: The Ontario Symposium (Vol. 8, p. 135). Psychology Press.
Kawachi I, Kennedy BP. 1997. Health and social cohesion: why care about income inequality? BMJ 314:1037–40.
Marchant, A., Hawton, K., Stewart, A., Montgomery, P., Singaravelu, V., Lloyd, K., ... & John, A. (2017). A systematic review of the relationship between internet use, self-harm and suicidal behaviour in young people: The good, the bad and the unknown. PLoS One, 12(8).
Office of the Arizona Governor, Doug Ducey. (2019, September 11). Governor Ducey Signs "Mitch Warnock Act" With Family, Advocates, Legislators [Press release]. Retrieved from https://goyff.az.gov/goyff/news/governor-ducey-signs-mitch-warnock-act-family-advocates-legislators
Rogers, E. M. (2010). Diffusion of innovations. New York: The Free Press/Simon & Schuster Inc.
Thacker, S. B., Berkelman, R. L., & Stroup, D. F. (1989). The science of public health surveillance. Journal of public health policy, 10(2), 187-203.
Thacker, S. B., & Stroup, D. F. (1994). Future directions for comprehensive public health surveillance and health information systems in the United States. American journal of epidemiology, 140(5), 383-397.
Vayena, E., Mastroianni, A., & Kahn, J. (2012). Ethical issues in health research with novel online sources. American Journal of Public Health, 102(12), 2225-2230.
Trout DL. 1980. The role of social isolation in suicide. Suicide Life-Threat. Behav. 10:10–23.
Velasco, E., Agheneza, T., Denecke, K., Kirchner, G., & Eckmanns, T. (2014). Social media and internet‐based data in global systems for public health surveillance: a systematic review. The Milbank Quarterly, 92(1), 7-33.
Wallach, W. (2015). A dangerous master: How to keep technology from slipping beyond our control. New York: Basic Books/Perseus Books Group.
World Health Organization. (2017). WHO guidelines on ethical issues in public health surveillance. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/255721/9789241512657-eng.pdf
Wray, M., Colen, C., & Pescosolido, B. (2011). The sociology of suicide. Annual Review of Sociology, 37, 505-528.
Zuboff, S. (2019). The age of surveillance capitalism: The fight for a human future at the new frontier of power. New York: PublicAffairs/Hachette Book Group.