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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: THE AMERICAN JOURNAL OF BIOETHICS 2020, VOL. 20, NO. 10, 50-60 https://doi.org/10.1080/15265161.2020.1806374 ® Taylor & Francis Taylor& Francis Group Duties When an Anonymous Student Health Survey Finds a Hot Spot of Suicidality 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. CASE 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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