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20 Am. J. Bioethics 50 (2020)
Duties When an Anonymous Student Health Survey Finds a Hot Spot of Suicidality

handle is hein.journals/ajbio20 and id is 1083 raw text is: 

2020, VOL. 20, NO. 10, 50-60

® Taylor & Francis
     Taylor& Francis Group

Duties When an Anonymous Student Health Survey Finds a Hot Spot of

Arnold  H. Levinson'ab    , M. Franci Crepeau-Hobson`,   Marilyn  E. Coorsa'd, Jacqueline J. Glover 'd,
Daniel S. Goldberg'd,  and  Matthew   K. Wyniaa'd
'University of Colorado Anschutz Medical Campus; bColorado School of Public Health; cUniversity of Colorado Denver; dCenter for
Bioethics and Humanities

   ABSTRACT                                                                               ARTICLE HISTORY
   Public health agencies regularly survey randomly selected anonymous students to track  Received 19 October 2019
   drug use, sexual activities, and other risk behaviors. Students are unidentifiable, but a recent  Revised 1 February 2020
   project that included school-level analysis discovered a school with alarmingly prevalent stu-  Accepted 17 February 2020
   dent suicidality. Given confidentiality protocols typical of surveillance, the surveyors were
   uncertain whether and how to intervene. We searched literature for duties to warn at- risk  KEYWden esures
   groups discovered during public health surveillance, but we found no directly applicable school anonymity; duty to
   guidance or cases. Reasoning by analogy, we conclude that surveyors should contact the warn; public health
   school's leaders to call attention  to  its outlier status, but public  warning  is  unwarranted.  surveillance ethics;
   However, such an ad hoc decision to issue a warning, even if only to school leaders, raises  suicidality clusters;
   significant practical, legal and ethical issues. National public health and education associa-  community protections

We   present and  analyze  a case of public health  sur-
veillance that raised questions about duties to prevent
harm   and  to protect confidentiality. The case brings
into focus several important  ethical concerns that can
arise when  a  surveillance activity identifies a popula-
tion  subgroup   with   elevated  levels of  a  danger-
ous behavior.


In  2013, a  biennial state-level student health survey
directed  by  one   of the  authors   (AHL)   measured
health-risk attitudes and behaviors  among   a probabil-
ity  sample   of  middle   and   high  school  students
(n = 40,207) in 224  randomly  selected schools. Topics
ranged  from   insufficient consumption   of fruits and
vegetables to cigarette and  drug use, to suicidal idea-
tion,  plans,  and   attempts.   Data   were   collected
anonymously,   with  no way  to  back-link responses  to
students,  a standard  practice  because  public  health
agencies use  such surveys only  to address population-
level rather  than  individual  concerns,  and  because
anonymity   fosters honest responses to sensitive behav-
ioral   questions.   Sampled     students   were    told

participation was voluntary  and that neither participa-
tion nor nonparticipation  would  have academic  conse-
quences.   Parents  provided   consent,  either actively
(parent  must   submit  signed  approval)  or  passively
(parent may  submit  signed disapproval)  as determined
by  schools. To   encourage   school  participation and
promote   local use  of  results, school administrators
were   promised    reports   of   their  site's  results.
Confidentiality  agreements   gave  administrators  sole
authority  to determine  whether,  how   and  to whom
their  school's aggregated   results would   be  shared,
including  whether  aggregated  results would   be pro-
vided to parents.
   During  preparation  of school-level reports, analysts
noticed  that one  middle  school  had alarmingly  high
rates of mental  health concerns. An  estimated  38%  of
the  student  body  (53%   of females,  25%   of males)
reported  they had  felt sad or  hopeless  almost  every
day for two  weeks in the past 12 months;  31%  (40%  of
females, 22%   of males)  reported  they  had  seriously
thought  about  suicide; 17%  (25%  of females,  10%  of
males)  said they had  made   a suicide plan,  and  13%
(19%  of females, 8%  of males)  had attempted  suicide.
All  rates  were   two  to  three  times   higher  than

CONTACT Arnold H. Levinson    arnold.levinson@cuanschutz.edu   Colorado School of Public Health, 13001 East 17th Place, Mail Stop F542, Aurora,
CO 80045, USA.
   Supplemental data for this article can be accessed at publisher's website.
C 2020 Taylor & Francis Group, LLC

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