Public health ethics and practice

Peckham, Stephen, Hann, Alison, Stephen Peckham, Alison Hann

• Publisher: Policy Press
• Year: 2009
• Print ISBN: 9781847421036
• eBook ISBN: 9781447315308
• Edition: 1
• Topic: Medicine
• Subtopic: Epidemiology

Ethical dilemmas are not new in the area of health care and policy making, but in recent years, their frequency and diversity have grown considerably.All health professionals now have to consider the ethical implications of an increasing array of treatments, interventions and health promotion activities on an almost daily basis. This goes hand in hand with increasing medical knowledge, and the growth of new and innovative medical technologies and pharmaceuticals. In addition, the same technology and knowledge is increasing professional and public awareness of new potential public health threats (e.g. pandemic influenza).

At the level of public policy, concerns over the rising costs of health care have led to a more explicit focus on 'health promotion', and the surveillance of both 'patients' and the so-called 'worried well'. Health professionals and policy makersalso have to consider the implications of managing these risks, for example restricting individual liberty through enforced quarantine (in the wake of SARS and more recently swine flu) and the more general distribution of harms and benefits.Balancing the rights and responsibilities of individuals and wider populations is becoming more complex and problematic.

This book will play a key role in opening out a discussion of public health ethics. It examines the principles and values that support an ethical approach to public health practice and provides examples of some of the complex areas which those practising, analysing and planning the health of populations have to navigate. It will therefore be essential reading for current practitioners, those involved in public health research and a valuable aid for anyone interested in examining the tensions within and the development of public health.

Part One
Public health: contexts

TWO

Why ethics? What kind of ethics for public health?

Alan Cribb

It would be very odd to insist that clinical health professionals should be mindful of, and conscientious about, the ethical issues raised in their one-to-one clinical encounters without setting similar expectations for those who work with whole populations. But – as I will suggest (and indeed this book shows more generally) – public health ethics raises many deep-seated and testing philosophical and practical challenges and those who work in, and are concerned with, public health have plenty of important things to be getting on with, without getting bogged down in an academic ethics seminar. So can we develop the field of public health ethics in a way that does justice to the imperatives of ethics and the imperatives of public health? Can we have an ethics for public health? With these questions in mind I will use this chapter to briefly review some of the philosophical, methodological, professional and policy challenges raised by the project of public health ethics.

Ethics avoidance

One way to deal with the many challenges inherent in public health ethics is to engage in what I will call – just to be slightly provocative – ‘ethics avoidance’. This is a widespread phenomenon both inside and outside public health contexts. Ethics avoidance encompasses a range of potential strategies. Here I will just mention three popular strategies which can be combined in various ways. First, there is ‘technicism’ – this means treating all issues as if they were fully susceptible to technical reasoning and practical problem-solving techniques. For example, given that we are committed to reducing population levels of morbidity and mortality (and/or some other end) then we must focus on identifying and implementing the best evidence-based methods of achieving this (or other) end. This latter can then be treated essentially as a scientific-technical question which we can – and arguably should – address without being distracted by ethical speculations. Second, there is an approach that might be called ‘conformism’ or ‘compliance’ and rests on an appeal to social and political authority. This approach consists in saying “It is not up to me to decide what ought to be done. Other people (managers, official agencies, the government) are properly charged with that kind of responsibility. My role is to do my job properly.” In practice this might, for instance, entail accepting the framework of targets that has been adopted by a local authority under a nationally defined programme and working with a technical and problem-solving mindset to deliver on those targets. Third, there is an appeal to ‘public opinion’ or some generalised notion of a democratic mandate – for example, by ‘testing’ the acceptability of proposed interventions through a process of consultation with potentially affected parties (to coin an ugly word, we might, therefore, call this ‘acceptabilism’). Obtaining a sufficient degree of support or popular authorisation can thus be treated as a substitute for, or perhaps as a form of, ethical validation. Clearly, strategies two and three are easily combined in those instances where we envisage the source of authority (perhaps the government) as possessing a measure of democratic authorisation.

Strategies of ethics avoidance flourish because they allow us to steer clear of the deep-seated puzzles generated by thinking about ethics and they allow us to get on with confronting practical public health problems. A world in which we each had to believe we had resolved all relevant ethical dilemmas before we could ‘go to work’ is not necessarily a desirable world to live in – far from it. Having said that, I would also contend that ethics avoidance simply won’t do. Each of the three strategies I have mentioned has a place – indeed each can be said to have some ethical relevance (that is, ‘what works’ matters; there is a place for authority, and ‘democracy’ or some notion akin to ‘consent’ is ethically significant). But a few minutes’ reflection should indicate why, taken individually or together, these strategies are not an adequate basis for ethically defensible policy making. We know from many other circumstances that popular support (or some simple conception of democratic approval) is not a litmus test for what is right or good – all kinds of atrocities can be ‘authorised’ in this manner. The same applies to appeals to social or political authority – the claim that “I am only doing my job” is notorious for being an inadequate response to ethical challenges. Finally, technicism fails on two counts. It leaves aside the central question of what we ought to do, and it treats policy or practice decision making as if it were simply about finding the most effective means to specified ends, when means and ends are not so easily separated out and when there is much at stake in deciding how we should act and not just in deciding what we ought to be aiming at.

Ethical debates are intrinsic to public health. Furthermore, ethical issues are frequently recognised and deliberated about in public health policy and practice (even if not always explicitly using the language of ‘ethics’). It is, for example, common to have discussions about whether certain policies take proper account of, and are respectful towards, differences in the preferences, identities and cultures of individuals and groups. It is equally commonplace to hear concerns about fairness or social justice – asking, for example, whether the benefits and burdens of public health initiatives fall in the right places. These are some of the key ways in which the ‘rights and wrongs’ of public health are routinely discussed. Debates about the potential and actual ‘harms and benefits’ produced by public health work are even more widespread. Indeed this concern with identifying the ‘goods’ produced or undermined by interventions is at the heart of the scientific-technical approach to public health. These preoccupations (with respect, with fairness, with harms and with benefits) reflect the core business of ethics and are famously summarised in the oft-cited ‘four principles’ of healthcare ethics (Beauchamp and Childress, 2001).

The disciplinary and professional cultures of public health thus provide both good news and bad news for anyone wishing to strengthen the field of public health ethics. There is widespread recognition of the ethical dimensions of public health decision making but there is, I would suggest, also a tendency not to focus sustained and systematic attention on these issues, and sometimes to positively avoid them either by conflating ethical questions with technical questions or by ‘assigning them’ to someone else. Ethical issues have a philosophical component, that is to say they concern questions which cannot be satisfactorily addressed by purely empirical or logical means. Rather, they require a capacity to engage in open-ended deliberation and argument about rival and often equally plausible (or apparently compelling) positions. What is needed from public health practitioners, I will suggest, is not necessarily an enthusiasm for, or expertise in, this kind of philosophical reasoning (some may well have these qualities, but it is not reasonable to expect them from everyone, just as it is not reasonable to expect interest or expertise in statistics from everyone), but simply an acknowledgement of this philosophical dimension, and a willingness, in dialogue with others, to take it seriously. I will also suggest, however, that philosophy is by no means enough. Public health ethics – if it is to be useful as well as rigorous – also depends on academic interdisciplinarity and on immersion in the contexts of practice.

The nature (and relative distinctiveness) of public health ethics

Discussions about public health ethics often begin by emphasising its distinctiveness. I will follow this precedent. In particular, in the remainder of this chapter I will focus on the kinds of questions and the kinds of methods that, I suggest, mark out public health ethics as rather different from clinical ethics. However, I should also stress that in reinforcing this notion of distinctiveness I am also quite deliberately overstating some of the differences between public health ethics and clinical ethics. This is in part because there is considerable practical overlap between the concerns of clinical healthcare and those of public health; but also – and I have tried to argue this at greater length elsewhere (Cribb, 2005) – because the ethical issues that arise at population levels are also, in various respects, relevant to clinical ethics, that is, clinical ethics ought itself to be understood in the context of public health ethics.

One way of approaching the relative distinctiveness of public health is to see that public health cuts across the boundaries of the professional and the political realms. In some respects traditional constructions of professionalism and the professional–client relationship can be applied to public health, but in other ways they break down or at least have to be rethought. On the one hand, public health work can be treated as a form of professional work, as something done by specific sets of practitioners and as thereby subject, for example, to theories about professionalism and professional virtues. On the other hand, analysing public health means taking an interest in much broader and more diffuse public policy processes and, for example, in competing political ideologies. This ambiguity about the relevance of the professional–client model applies to the population orientation of public health (that is, who is the client?); to the teamworking and intersectoral dimensions of public health work (that is, who is the professional?); and to the future and preventive orientations of public health – that is, if there is a client, they are not necessarily asking for help or being ‘treated’ in relation to current needs. This means that when we ask key questions in public health ethics we do so from a position which can feel unbounded by and somehow adrift from the familiar conventions of healthcare professional ethics. Specifically, problems of agency and responsibility are always to the fore in public health ethics – it is always relevant to ask “who has responsibility for what?”. One of the things at stake is the ‘division of ethical labour’ – the question of the respective responsibilities of the government, other institutional agencies, individual citizens and health professionals, including public health practitioners.

Public health ethics – two key questions

There are various ways in which the core questions of public health ethics could be stated and classified. Here I will just provide a summary account of two broad indicative questions which will, I hope, also serve to further illustrate the distinctiveness of the domain. I will review them in a very general and abstract way, but it may be worth underlining the fact that they will not arise in this general form but will be embedded in specific substantive questions about what to do in relation to diverse public health agendas.

What are the goals of public health?

This question can be unpacked into a range of smaller questions. There are, for example, questions about the conceptions of health employed in public health – how far ought we to be focusing upon narrow but clinically well-defined conceptions of morbidity, or using broader and more diffuse notions such as well-being or quality of life? This is a complicated but very familiar conundrum and I won’t dwell on it here except to stress that this is not just a dispute about indicators or measures, but is a dispute about what – ultimately – matters (or at least what ought to be the proper business of public health).

Public health also gives rise to overlapping and analogous questions about the conceptions of ‘public’ in public health – that is, there are both informal and technically defined conceptions of ‘public goods’ as opposed to individual goods. Many public health initiatives are aimed at ends that are provided and experienced collectively. For example, a community development team may help support work on green spaces or cycle ways both as means of promoting healthy life-styles and for the intrinsic benefits they bring. These are very different ‘goods’ from the exercise bike or the over-the-counter medicines that individuals may buy and use for themselves precisely because they contribute something to the community way of life – they are shared goods or common goods, and they embody and support forms of relatedness and not just individual outcomes. In the technical sense (derived from economic analysis but also deployed in the philosophical literature), public goods have the properties of being ‘indivisible’ (not separable out into separate units), ‘non-excludable’ (open to being enjoyed by all and not confined to private hands) and ‘cooperation dependent’ (owing their existence to the cooperation of many) (Klosko, 1987; Dawson and Verweij, 2007). Many of the goods that public health is concerned with – such as ‘clean’ air or herd immunity – are public goods in this sense. But we can use the idea of public goods in an extended and less formal sense simply to mean ‘collective goods’ and to underline the distinctive orientation of public health towards groups and communities as something over and above a collection of individuals. For example, access to clinical health services can be treated as an individual good. But the idea of a community underpinning individual access to healthcare represents something more than an aggregation of individual goods – it can be seen to embody forms of relational or civic goods such as ‘solidarity’. The tensions between population-oriented goods (whether or not ‘public goods’ in the technical sense) and individual goods come to a head when something that is deemed beneficial for a population causes harms of one kind or another to specific individuals (I will discuss this further in relation to the next question).

Finally, the focus upon collective goods raises related but distinctive concerns about health inequalities. How far, and in what respects, is it the function of public health to address health inequalities? In some ways a focus on using public health efforts effectively will coincide with a concern with addressing inequalities in health – because, up to a point, resources directed towards the less-advantaged have the potential to enhance ‘health outcomes’ (however defined) most effectively. But in many cases there is an apparent tension between these two sets of concerns – for example, sometimes resources directed at ‘hard to reach’ groups may yield very few public health benefits as compared with resources invested in better-off populations. Here we are faced with very difficult technical and ethical choices, including choices between effectiveness and efficiency on the one hand, and equity and solidarity on the other. (And, of course, for anyone who accepts an analysis like Richard Wilkinson’s (2006), that equity and solidarity may themselves be causally implicated in the production of overall health and well-being outcomes, this balancing act is reframed and further complicated.) I will not say much more about health inequalities here, but will return to this theme in the conclusion.

In short, public health faces continuous contests about narrow versus broad conceptions of health, about public versus individual goods, and about efficiency versus equality. These diverse concerns about the ends of public health can be used to illustrate the peculiar complexity of public health ethics. I can underline this point by drawing a crude – indeed exaggerated – contrast with clinical ethics. If we imagine a patient in need of a hip replacement consulting a doctor, we can envisage a whole range of possible ethical issues arising. For example, where on the waiting list should the patient be placed, in how much detail should the doctor outline the possible complications of the operation to the patient, and so on? However, the ethical issues in this instance seem largely to relate to the ‘when’ and the ‘how’ of treatment rather than to the ‘what’; that is, in the specified scenario there is a mutual understanding of and agreement about the core goals. When it comes to public health, things are very rarely like this. There is almost always a great deal of contestability about goals, about what we should be collectively aiming at, and (as I just noted above) about who should be responsible for decisions and actions. Public health ethics is inherently multi-dimensional and, in particular, ethical issues abou...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Acknowledgements
• Contents
• Notes on contributors
• ONE: Introduction: Why public health ethics?
• Part One: Public health: contexts
• Part Two: Ethics and public health practice
• Part Three: Public health ethics: developing a basis for practice