Description
Using the Ethics and Public Health Model Curriculum found in the Course Library Reading List, read Modules 1-4. Then, agree on an ethics issue from one of the Case Studies in Modules 5-9. Provides a background description of the ethical issue;Addresses how professionalism will be required to address this concern;Discusses how the legal standards of health care practice come into play (see Module 1, p. 13); andDescribes how interdisciplinary collaboration can be achieved through leadership and community stewardship to address this ethical issue (see Module 4, p. 103).https://repository.library.georgetown.edu/bitstrea…
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Ethics
and
Public Health:
Model
Curriculum
Editors:
Bruce Jennings, MA
The Hastings Center
Jeffrey Kahn, PhD, MPH
University of Minnesota
Anna Mastroianni, JD, MPH
University of Washington
Lisa S. Parker, PhD
University of Pittsburgh
Ethics and Public Health:
Model Curriculum
Editors:
Bruce Jennings, MA
The Hastings Center
Jeffrey Kahn, PhD, MPH
University of Minnesota
Anna Mastroianni, JD, MPH
University of Washington
Lisa S. Parker, PhD
University of Pittsburgh
This project was supported under a cooperative agreement from the Health Resources and Services
Administration (HRSA) through the Association of Schools of Public Health (ASPH). Grant Number 1D38AH10001-05. The contents of this report are solely the responsibility of the authors and do not
necessarily represent the official views of HRSA or ASPH.
Preface
There is a growing interest in the ethical, legal, and social aspects of public health policy and practice.
This interest no doubt has been fueled by the threat of bioterrorism after 9/11. But it had been growing
for some time before that in the wake of various infectious disease outbreaks and with the growing
recognition that public health issues are inseparable from issues of human rights and social justice,
problems of cultural and behavioral change, and environmental issues on a global scale. With this
growing interest in ethics in public health comes a demand for the teaching of ethics and for resource
materials to support it. Ethics education is needed both in pre-professional degree and certificate
programs, and in settings of continuing professional education. This model curriculum for Ethics in
Public Health is intended as a resource to enhance and encourage thoughtful, well informed, and
critical discussions of ethical issues in the field.
Ethics in Public Health: A Model Curriculum grew out of a series of meetings and discussions by
leading researchers and educators in public health beginning with a meeting convened in Washington
DC in May 2000. This meeting was sponsored by the Association of Schools of Public Health (ASPH)
and the Health Resources and Service Administration (HRSA). It brought together teachers of ethics
from nearly every school of public health, other experts in ethics and public health, and representatives
of the government and public health practice communities. One of the clearest recommendations to
come out of that meeting was that educational materials and resources should be developed to enhance
curricular and continuing professional education offerings. HRSA generously agreed to fund the
development of a collection of modules, through their Cooperative Agreement with ASPH.
In June 2001 a special advisory group was formed and met in Washington to plan the new curriculum.
During this period The Hastings Center was working on a project funded by the Robert Wood Johnson
Foundation to promote the discussion of ethical issues within public health. This effort converged so
well with the HRSA/ASPH effort that the two groups joined forces and their collaboration began with
the advisory meeting. At that meeting it was agreed that the curriculum would take the form of several
self-contained units or modules, each written by a leading expert on the topic in question, and each
containing the same types of resources for classroom use—an analysis of the ethical question, several
case studies with commentary for discussion, resources for further study and research, and the like.
Shortly after the June 2001 advisory group meeting experts in ethics and public health were recruited to
write the modules, with the understanding that they would work closely with local members of the
public health practice community to be sure that concerns and issues from the practice community were
well represented. The input of the practice community was critical to the quality and credibility of the
modules, and we thank these consultants for their generous participation.
During the period in which the modules were being developed, meetings and workshops continued the
discussion begun in Washington. These included a working group on ethics and public health at The
Hastings Center, a summer workshop on ethics and public health co-sponsored by the University of
Minnesota Center for Bioethics and The Hastings Center, and conference workshops on teaching ethics
in public health at annual meetings of both the American Public Health Association and the American
Society for Bioethics and Humanities.
We trust that this collection will serve as the springboard for many discussions of public health ethics in
classrooms and workshops, and we hope that the curriculum development discussion continues as well.
v
Since the modules exist in electronic form, we see them as continuing works in progress. To that end,
we hope that those who use these materials will provide us with feedback about what works, what needs
improvement, and what additional information and topics might be added to future editions of this
curriculum. You can e-mail your comments to either Jeff Kahn at [email protected], or Bruce
Jennings at [email protected] and please type “public health ethics
modules” in the subject line.
The development of this curriculum was made possible by the support of HRSA and the Robert Wood
Johnson Foundation, and through the cooperation of ASPH, the University of Minnesota Center for
Bioethics, and The Hastings Center.
Finally, the entire project could not have been completed without the staff at ASPH, who included
Wendy Katz, Sandra Maldague, and Monica Stadtler. We thank them, along with all those who
participated in the many workshops and conferences for their input and insights. Lastly, we offer our
sincere thanks to the modules’ authors who enthusiastically undertook the task of creating this valuable
resource for the public health community.
Bruce Jennings
Jeffrey Kahn
Anna Mastroianni
Lisa Parker
July 2003
vi
LIST OF CONTRIBUTORS
Hilary K. Alvarez
Dartmouth College
Ronald Bayer, PhD
Joseph L. Mailman School of Public Health, Columbia University
Ruth Gaare Bernheim, PhD
Institute for Practical Ethics, University of Virginia
Richard Bonnie, LLB
School of Law, University of Virginia
Michael Garland, D.Sc.Rel.
Department of Public Health and Preventive Medicine, Oregon Health & Science University
Lawrence O. Gostin, J.D., LL.D (Hon.)
Georgetown University Law Center
Elizabeth Heitman, PhD
University of Mississippi Medical Center, Jackson, Mississippi and
University of Texas School of Public Health, Houston, Texas
Bruce Jennings, MA
The Hastings Center
Jeffrey Kahn, PhD, MPH
Center for Bioethics, University of Minnesota
Patricia A. Marshall, PhD
Department of Bioethics, Case Western Reserve University
Anna C. Mastroianni, JD, MPH
University of Washington School of Law and Institute for Public Health Genetics
Laura C. McKieran, DrPH
El Centro del Barrio, San Antonio, Texas
vii
Phillip Nieburg, MD, MPH
Center for Biomedical Ethics, University of Virginia
Lisa S. Parker, PhD
Center for Bioethics and Health Law, University of Pittsburgh
Kristin Shrader-Frechette, PhD
Department of Biological Sciences and Department of Philosophy, University of Notre Dame
John Stull, MD, MPH
Department of Public Health and Preventive Medicine, Oregon Health & Science University
James Thomas, MPH, PhD
School of Public Health, University of North Carolina at Chapel Hill
Stephen Thomas, PhD
School of Public Health, University of Pittsburgh
viii
TABLE OF CONTENTS
Module 1:
Tradition, Profession, and Values in Public Health
Lawrence O. Gostin, J.D., LL.D (Hon.) ……………………………………………………………..Page 13
Module 2:
The Legacy of the Tuskegee Syphilis Study
Lisa S. Parker, PhD; Hilary K. Alvarez; Stephen Thomas, PhD ………………………………..Page 37
Introduction to Modules 3 and 4:
Research Ethics in Public Health
James Thomas, MPH, PhD …………………………………………………………………………….Page 75
Module 3:
Public Health Research and Practice in International Settings: Special
Ethical Concerns
Patricia A. Marshall, PhD………………………………………………………………………………Page 85
Module 4:
Community-Based Practice and Research: Collaboration and Sharing Power
Elizabeth Heitman, PhD; Laura C. McKieran, DrPH ……………………………………………..Page 103
Module 5:
Ethics and Infectious Disease Control: STDs, HIV, TB
Ronald Bayer, PhD ………………………………………………………………………………………Page 133
Module 6:
Ethics of Health Promotion and Disease Prevention
Ronald Bayer, PhD ………………………………………………………………………………………Page 147
Module 7:
Ethical Issues in Environmental and Occupational Health
Kristin Shrader-Frechette, PhD ……………………………………………………………………….Page 159
Module 8:
Public Health Genetics: Screening Programs and Individual Testing/Counseling
Ruth Gaare Bernheim, PhD; Richard Bonnie, LLB; Phillip Nieburg, MD, MPH……………Page 193
Module 9:
Public Health and Health System Reform: Access, Priority Setting, and
Allocation of Resources
Michael Garland, D.Sc.Rel.; John Stull, MD, MPH ………………………………………………Page 241
ix
INTRODUCTION:
A Strategy for Discussing Ethical Issues in Public Health
Bruce Jennings, M.A.
The Hastings Center
Yale School of Public Health
This is a general introduction and orientation to the ethics and public health curriculum. It explains the
goals and strategy for ethics education and training and provides guidance about the skills of facilitating
an ethics discussion with adult learners.
Why This Curriculum Was Created
Public health policy and interventions are always the product of controversy, and often remain
surrounded by controversy as they are implemented. Routinely in public health, scientific considerations
blend with political and ethical conflicts, and questions of autonomy, individual rights, coercion,
justice, community, the common good, the norms of research, and multi-cultural values are central. In
public health today several different types of political and moral theory overlap, converge, and contend
with one another, including libertarian liberalism, egalitarian liberalism, utilitarianism, human rights
frameworks, and communitarianism. This curriculum will explore the “application” of ethics to a broad
range of contemporary public health issues. It is intended for use both in pre-service educational
programs at the undergraduate and graduate level, and for in-service continuing professional education
settings in public health agencies and related organizations.
This curriculum and facilitator’s guide offers a planned approach to the discussion of ethical and values
issues in public health. It is designed to help you identify appropriate topics and issues for discussion—
issues that are pertinent to the public health practitioner and policymaker, and issues that lend
themselves to an in-depth discussion of the often-conflicting values and ethical dilemmas raised by
current public health knowledge and its applications.
Ethical issues are rarely neat, tidy, or cut-and dried. The questions of genetics, international and
community based research, the control of infectious disease, and others that have been selected for this
program are particularly difficult. They pose ethical “dilemmas” rather than black and white moral
questions. They involve quandaries about which well-informed persons of good will can reasonably
disagree.
For this reason, these materials will not offer clear-cut answers to many of the ethical issues raised. The
best and most responsible thing an educational program can do in the face of these moral and social
dilemmas is to provide public health practitioners with many perspectives on the issues, and to guide
their own reasoning processes toward conclusions with which not everyone will necessarily agree, but
which can stand up under close scrutiny and open dialogue with others.
Introduction
1
What is Ethics?
Terms like “ethics,” “morals,” “morality,” and “values” will occur frequently in this curriculum. It would
be helpful to define them clearly and succinctly at the outset. Unfortunately, however, this is not easy or
even possible to do.
Ethics and morals are most often used interchangeably, so that the sentence “He acted ethically,” and
the sentence “He acted morally,” mean the same thing. Sometimes, though, morality (or morals) is
defined as the beliefs and standards of good and bad, right and wrong, that people actually do and
should follow in a society, while ethics is defined as the systematic study of morality. Ethics, in other
words, is the theory and morality is the practice; morality is what people do and believe, ethics gives a
philosophical account of justified behavior and belief.
Moral values are those things that people should prize and promote. Values are names for states of
affairs that conform to what is ethically right and that further the human good (or the good of all
beings).
Understood as the systematic study of morality, ethics is often divided into two subfields, metaethics
and normative ethics. The relationship between them may be compared to the relationship between the
philosophy of science, on the one hand, and science itself, on the other. Metaethics tries to clarify the
rational standards and methods for the study of ethics, much as philosophy of science tries to clarify the
nature and method of scientific inquiry. Normative ethics is where the substance of ethics resides. It
develops ethical principles, rules, and ideals that spell out standards of good and bad, right and wrong.
Normative ethics tries to offer a substantive, albeit general answer to the questions, What should I do?
And How ought I to live? And it tries to spell out reasons why a rational person ought to accept the
answer it gives.
Bioethics is normative ethics applied to decisionmaking and public policy in the domains of biology,
medicine, and health care. It is concerned with matters of basic scientific research and with the social
applications of biological knowledge and biomedical technology. Medical ethics, the ethics of the
physician’s role, is as old as medicine itself. But bioethics is a newer, broader field of study that has
arisen largely during the past twenty to thirty years as new powers, new choices, and new dilemmas have
been opened up by the biological revolution.
Public health ethics, in turn, has arisen along side bioethics and the two fields of applied ethics have
many strong affinities and connections. Just as the perspective and focus of public health often differs
from that of clinical medicine, however, so too are there important differences between bioethics and
medical ethics, on the one hand, and public health ethics on the other. In a nutshell, the difference can
be characterized by the individualistic orientation of clinical medicine and the social or population
based perspective of public health. Public health deals with patterns of disease, the social determinants
of disease, and collective and institutional solutions to alleviate the risk or burden of disease in a
population and to affect the distribution of health benefit and disease burden in a society, or globally.
Nonetheless, public health should not overlook the rights, interests, and freedom of the individual.
Whenever possible, public health goals should be reconciled with the promotion of human rights and
the protection of civil liberties. If there is an inevitable clash between public health and civil liberties,
then the situation must be open to public debate, the elements of the conflict should be made explicit,
Introduction
2
and rigorous, critical reasoning should be brought to bear on the relative benefits and burdens of a
particular policy or intervention.
A Strategy for Ethics Education
Many teachers or facilitators find group discussions of ethics and values frustrating and difficult because
such discussions tend to jump all over the place. They may seem to have no rhyme or reason, no logical
order or sequence of information to discover and points to consider. Ethics discussions seem to have
no starting point, no sense of progress and forward movement, and, worst of all, no satisfying
resolution or conclusion.
Ethics discussions need not be like this; they need not be an educator’s nightmare. They can—and
should—follow an orderly progression of steps. And they can end, if not always with firm, agreed-upon
conclusions, then at least with the feeling that something has been clarified—people have been led to
think.
As with any education program, regardless of the subject matter, achieving these results when
discussing public health ethics requires careful planning and some background preparation by the
discussion leader or facilitator. If you have a good grasp of the issues on all sides of a question (which
is not the same thing as having strong personal convictions on one side or another), then you will be in
a position to guide the class discussion so that the participants are led to discover and express these
issues themselves and to think thoroughly about the pros and cons. Much of the material in this
instructor’s guide is designed to provide the background information and ideas that will assist
facilitators in this way.
Moreover, to keep the participant’s thinking about ethical questions focused and moving forward, you
need to devise a strategy for analyzing ethical questions in concrete cases or situations. A strategy for
guiding discussion and learning gives you an overview of what a good ethics discussion should contain
and where it should lead.
The strategy we recommend for use with these educational materials and case studies consists of the
following six steps or tasks to complete during each module. Completing these tasks is one way to
provide a structure for discussion and to keep it focused. Completing these tasks is also one way to
ensure that the participants are given a thorough exposure to the ethical issues in each unit.
Identify the ethical problem(s) germane to the decision. What has to be decided, by whom, and
what ethical problem(s) does this decision seem to raise? In complex cases this problem identification
step will actually be only a “first cut”; the identification of the problem will be refined and revised as the
situation is understood more deeply and as the ethical values and concepts that explain why the
problem is a problem are articulated.
Assess the factual information available to the decisionmaker(s). Of all the facts that are known
now, which are relevant to the ethical problem, and which are not relevant? For example, the fact that a
pregnant woman has brown hair is not relevant to the ethical question of genetic screening, while the
fact that she has a history of cystic fibrosis in her family is. Equally important, what is not known that
should be known before a decision is made, and how can that information be obtained? Finally, how
Introduction
3
reliable is the information we have, and what type of information is it? How can we separate fact from
hearsay or opinion? How can we assess probabilistic information in making ethical decisions?
Identify the “stakeholders” in the decision. Who will be affected by the decision, and in what ways?
How directly will they be affected—if they will be harmed is the harm justified by greater benefit to
others? Is the harm intended by the decision-maker or is it merely foreseeable? Have they placed
themselves in a position to be harmed voluntarily and with appropriate information and understanding
of the risks involved? Or are they “innocent bystanders”? How do all these factors affect the weighing of
benefits and harms involved in the decision?
Identify the values at stake in the decision. Values are those things that have significance or worth
relative to some state of affairs, such as human well-being, respect for persons, or fairness that is taken
to be good or desirable in itself. In this step the values that seem relevant to the situation should be
identified and discussed. Here the instructor can provide a kind of common vocabulary of concepts to
assist with the discussion, for participants will often grasp the concept without having the commonly
used word or label to express it. Freedom, truth telling, protecting another from harm, fairness, respect
for other people, empathy, altruism, the growth of scientific knowledge—these are a few of the values
that are typically presented by cases in public health ethics.
Identify the options available to the decisionmaker. At first glance, many ethical cases seem to pose
very stark moral choices, even tragic choices where no outcome is without significant human cost. There
are tragic choices in life, it is true, and it is important for participants to be able to face that fact and
consider how they will learn to live with the decision they had to make. But it is equally important not to
give the impression that all moral choices are tragic choices. Part of the skill of thinking analytically
about moral decisionmaking is to see beyond artificially narrow options and forced choices. Insightful
moral reasoning is often a process of resisting forced choice, and wiggling out of a moral dead end in
order to find some more acceptable alternative. Would more information enable us to see more options
here? Can we wait until that information is available? Is some compromise or middle way possible that
will respect a broader range of values and more stakeholders’ interests than any other option? Ethical
decisionmaking is akin to creative problem solving, and seeking the Yes-Yes or Win-Win solution.
Consider the process for making the decision and the values that pertain to the process. A few
such values would be authority, legitimacy, participation, and due process rights to be heard and to
appeal. These topics may appear legalistic, but they apply in virtually any decisionmaking situation to
some extent, in families no less than in bureaucratic or legal settings. Should I be the one making this
decision? To what extent and in what ways should I involve others in the decision? Will the outcome of
my decision be shaped by the cooperation of others with the decision I have made, and will their
willingness to cooperate be shaped by whether or not they view my decision as fair and legitimate? If the
ethical justification of my decision hinges on a good outcome I expect, but if that good outcome
assumes the cooperation of others, then ethically I also have to take steps to assure that cooperation
beforehand. So what I decide is only half of the ethical equation. How I decide is also important.
What Should You Try To Accomplish?: Learning Objectives
The goals of ethics education at various developmental levels remains a subject of considerable
controversy. Our program does not assume that the teaching of ethics will automatically produce
professionals who are more ethical in their personal choices and behavior than they would be without
Introduction
4
the instruction proposed by the program. That goal demands too much—clearly there are many more
important sources of moral belief and motivation in their lives than a few hours of discussion in a
classroom or a conference room. But, in another way, that goal also demands too little—for the
teaching of ethics is concerned not only with how people behave but also with the reasons they have for
behaving as they do.
There are five general goals of ethics education that have guided the development of these materials
and that facilitators should bear in mind when using them.
1. Stimulating the Moral Imagination. Ethics education should produce a blend of cognitive and
affective components. Ethical thinking, judgment, and sensibility are neither matters of pure, abstract
intellect nor of unreflective “gut feelings” and prejudices. Regardless of the specific subject matter
under discussion, guiding your participants or colleagues through the components of ethical reasoning
can help them gain a better appreciation of the fact that human beings live their lives in a web of moral
relationships. It will also show them that moral conflicts, which are frequently inevitable and difficult,
involve high stakes in the lives of real people. Stimulating the moral imagination involves the ability to
gain a feel for the lives of others, some sense of the motions and the feelings that are provoked by
difficult ethical choices, and some insight into how moral viewpoints influence the way individuals live
their lives. And the goal is not simply to stimulate but also to broaden the moral imagination—to begin
with what people at first feel to be right or good, but then to deepen and sometimes to challenge and
change those feelings by transforming them into more reflective judgments and more sophisticated and
well-informed convictions.
2. Recognizing Ethical Issues. Ethics education is not unlike scientific education in one respect: it
involves a certain structuring of perception, a certain kind of “seeing as.” To see a certain state of affairs
or decision as a moral issue is to see that it raises considerations of human value, and that it has
significant implications for harms or benefits human beings experience. To see something as a moral
issue is also to see that it involves questions of human freedom and choice, that it could be different
from what it is, and that the way the choice it permits is made significantly affects the rights and wellbeing of individuals involved in or affected by the choice.
3. Developing Analytical Skills. Ethical analysis involves the use of a certain set of prescriptive and
evaluative categories, such as rights, duties, virtue, justice, responsibility, freedom, respect, dignity, and
well being. These categories comprise the basic moral vocabulary of our society. However, they are
difficult to define and their meaning is never determined once and for all, but is worked out instead in a
process of dialogue, moral disagreement and debate. Participants need to acquire the ability to use
these concepts in constructing arguments that are logical, consistent, and defensible in the face of
reasoned disagreement and challenge. Analytical skills also involve the ability to make conceptual
distinctions so that ethical claims are not unduly broad and undiscriminating. Finally, the ability to
detach oneself from personal interests and parochial perspectives is an analytical ability that must be
practiced and learned. During the course of discussion it is a good idea to check for the presence of
this detachment from time to time. If a participant states or agrees with a moral rule that would limit the
freedom of others, ask if he or she would be willing to have the rule applied to his or her behavior too.
4. Eliciting a Sense of Moral Obligation and Responsibility. Ethics discussions usually start with
simple assumptions and beliefs, challenge them, and replace them with more nuanced thinking. In this
way, ethical analysis sometimes makes moral choice more, not less, difficult and complex. And properly
Introduction
5
so. On the other hand, in ethics teaching you should be careful not to paralyze or intimidate the
participant with such hard cases or dilemmas that ethics seems hopeless. The point is to enable them to
make better, more thoughtful choices, not to make choices seem impossible or simply arbitrary, like a
coin toss. The goal is to enable participants to see when and how their own actions and choices do
make a difference in the lives of others as well as in their own life. It is to motivate them to take action
in accordance with ethical commitments and to assume a sense of responsibility for their own conduct,
as well as for the effects of their conduct on others.
5. Coping with Moral Ambiguity. It is simply a fact of life that we must learn to tolerate
disagreements and to accept the inevitable ambiguities that arise when examining ethical problems.
Many ethical issues admit of no final, clear resolution. Reasonable persons of good will may disagree on
the course of action that ethical considerations require. Yet while we must tolerate disagreement and
ambiguity, we must also attempt to locate and clarify the sources of disagreement, to resolve
ambiguities as far as possible, and to see if ways can be found to overcome differences of moral
viewpoint and belief. Group discussion built around the ethics modules in this curriculum can model
these goals. Through directed group discussion you can demonstrate that progress can be made in
reducing disagreement, and in gaining a narrower, and perhaps more manageable, area of
disagreement. It is important not to simply assert this but to show how it can happen. Participants
should be led to understand that there are general standards by which to judge the quality of ethical
arguments, that disagreements are inevitable but can be reduced, and that ethical perspectives can be
detached from pure subjectivity or self-interest. Questions of right and wrong, good and bad may finally
admit of no single or final answer, but this does not mean that the answers we do and must give are
simply matters of taste.
Leading Ethics Discussions
It is perfectly natural to feel uncomfortable with the subject matter of public health ethics and with the
special challenges of “teaching ethics.” Most public health professionals who will be using these
materials will not have any formal training in philosophy or ethics.
Make no mistake: the key to any successful group discussion of ethical questions lies in the skill of the
facilitator who guides the discussion and in the curiosity and engagement of the participants. They must
open their minds to unfamiliar ideas and learn to see connections between decision, actions, and their
consequences for the person, for others, and for society as whole. Curriculum materials can’t do the
work of good teaching. Drawing on the strengths that public health professionals can bring to the
task—maturity of judgment, logical reasoning and analytic skills, and mastery of the scientific subject
matter—we believe that these materials will provide you with the tools you need to handle ethical and
value questions in a constructive, thoughtful fashion with your participants.
You won’t be preaching to them. You won’t be giving them the definitive answers or imposing your own
personal moral beliefs on them. Nor will you be presiding over a session in which everyone simply
makes personal statements of their “values” without engaging in genuine dialogue or without being
called on to give reasons in support of their beliefs.
You will be helping participants and colleagues think more consistently and completely through
problems that they will have to face soon—or are facing now—in their own careers in public health.
Introduction
6
Each of the ethical topics in the program raises questions of choice—understanding the options one
has—and questions of responsibility—what values are at stake in one’s choices and what moral
principles, rights, and obligations should guide those choices. Eliciting a sense of responsibility on the
part of the participant is one important objective of all ethics teaching, and especially in health care,
where so many of the issues do in fact involve decisions that individuals will probably have to make
sometime in their lives, be it reproduction, medical care for a child or a loved one, or choices as
consumers and as citizens that affect the environment.
Before a discussion of ethics can get off the ground, two pervasive feelings, which are probably
widespread even among advanced students and public health professionals, must be overcome. The first
is a sense of powerlessness and alienation–the feeling that nothing one does as an individual really
makes any difference. When you feel helpless you are not prone to accept the idea that you have
responsibility for what happens to you or for what goes on in society. Of course, this perception is not
simply to be dismissed; there is a large kernel of truth in it. But it should not be allowed to lead to
apathy and the denial of the participant’s own moral agency and responsibility. The trick is to make
connections between the “big issues” and more tangible, controllable aspects of personal life, and to
lead the discussion beyond the classroom by considering ways participants can get involved in
community activities that address some of the problems discussed in class. These materials have
