Public Health:The Need for a New Ethic

Nuala Kenny OC, MD, FRCP(C)Francoise Baylis PhD

Department of BioethicsSusan Sherwin PhD

Department of Philosophy

DALHOUSIE UNIVERSITY Halifax, NS

The Issue

• Health care with its focus on individual patient benefit has dominated the policy agenda since the 1960’s– Clinical ethics

• Public health has been neglected– Neglect of public health ethics

• We have a ‘window of opportunity’

Wake Up Calls re PH

• Emerging infectious diseases e.g. Ebola(1977), legionnaires(1977), HIV/AIDS (1983), variant CJD (1996)

• Re-emergence of diseases like TB

• Water-Walkerton (2000)/ Battleford(2001)

• Risk of bioterrorism such as anthrax (2001)

• Chronic illness ‘epidemic’, environment

• SARS (2002-2003)-Naylor Report

Impending Crises and Emergency-Preparedness

Pandemic

• Pandemic and other emergency preparedness/response issues finally galvanized action on public health– In Canada

– Elsewhere

Pandemic Ethics-early recognition

• U of T– Singer et al, 2003 lessons from SARS

– Stand on Guard…2005• Issues: civil liberties, privacy, duty of car (patients &

workers),credit for research, patent protection

• Kotalik– Plans should be “…instruments for building mutual

trust and solidarity at such a time that will likely present a major challenge to our societies”

Canadian Plan-2004

• Protect and promote the public’s health

• Ensure equity and distributive justice

• Respect the inherent dignity of all persons

• Use least restrictive means

• Optimize the risk/benefit ratio

• Work with transparency and accountability

International Pandemic Ethics

• Over 37 national plans have been identified (uscher-Pines et al, 2007)

• WHO

• US

• New Zealand

Our Analysis of The ‘Problem’

• Inordinate focus on pandemic and emergency preparedness not full range of PH (cart before the horse!)

• Inordinate dependence on individualistic bioethical principles originally developed for research and clinical ethics (particular before the general)

Principles of Bioethics(Beauchamp & Childress)

• Respect for autonomy

• Beneficence

• Non-maleficence

• Justice

Traditional autonomy• Promotes personal values

• Concerned with competence and knowledge of agent

• Enhanced when free of “outside influences”

• Best captured by informed consent

• Individual judgment of benefit/risk/harm

Justice

• Neglected Principle– Generally focused on non-discrimination

• Distributive justice-sharing in material resources

• Social justice-sharing in power, voice

• Restorative justice-repairing/reconciling for past injustice

Our Challenge

• To develop an ethic for public health appropriate to its nature and all core functions

• Public health broadly or narrowly understood?

• Ethics as inherent to public health (not imposed from without)

Traditional Aims of Public Health

• Protect & enhance the health status of the population

• Reduce health inequalities (inequities)

Functions of Public Health

• Health promotion

• Health protection

• Disease and injury prevention

• Population health assessment

• *Disease and risk surveillance

• *Disaster and emergency response

Traditional Focus of PH

• Modifying conditions leading to disability and premature death

• Populations and communities

• Reducing health inequalities

• Health differences that are modifiable

• The most vulnerable

• Collaborative action & citizen engagement

Duty and Public* Health Policy

• Safety and protection of the public from harm

• Maintenance of public trust• Promotion of the public/common good• Clinician duty and risk

– *public meaning populations/communities– *public meaning collective interventions

Jurisdictional Issues

• Constitutionally, public health is provincial

• Practically, public health services are municipal

• New and emerging threats cross all borders

• Lack of clarity re jurisdiction was a major problem in the SARS epidemic

An Ethic for Public Health

• What conception of autonomy? • The common good?• The public interest?• Benefit/Harm/Risk judgments

– Who? On what basis?

• How ought we understand justice in public health?

Public Health Ethics

• A growing body of general ethicswork:– D Beauchamp, Childress et al, Kass, Callahan

& Jennings, Upshur, Dawson & Verweij etc.– A new Journal of Public Health Ethics– PHAC identification of the need to identify

“Foundational Issues in Public Health Ethics”

– Social justice and public health: Anand et al, Gostin & Powers, Powers & Faden, Uscher-Pines et al, the Bellagio group

So…….

• We need a ‘new’ more comprehensive and coherent ethic for public health

• An ethic that identifies substantive and procedural values and principles

• An ethic intentionally reflecting the commitment of public health to– Promoting the health of the community– The reduction of health inequities

A Relational Ethic for Public Health

• Relational autonomy

• Social justice

• Relational solidarity

Reject individualistic ethics

• Account for ways in which individuals are embedded within communities

• Interests of individuals and communities are interconnected

• Promote positive (relational) account to address these realities

Relational autonomy

• Judgments about autonomy must reflect on range and nature of choices on offer

• Differences in social location may produce different range of options

Social Justice

• “Social justice is the foundational moral justification for the social institution of public health” Powers & Faden, 2006

Social justice

• Distributive justice: focus on fair distribution of quantifiable benefits and burdens among individuals

• Social justice: fair access to social goods such as rights, opportunities, power, and self respect; focus on groups as well as individuals (Young)

Relational solidarity

• We need a fully inclusive concept

• The meaning of solidarity is found within public health

• It must reflect that we are not all equally situated or affected by public health concerns and policies

Relational solidarity

• Mutual (not equal) vulnerability

• Motivation for committing to hard work of solidarity

• Need to attend to social justice in pursuing solidarity to achieve goals of public health

Procedural Ethics

• Inclusive

• Transparent

• Precaution

• Subsidiarity

Conclusions

• Make visible the role of public health in promoting public goods

• Focus on relations among humans

• Develop a relational ethic– Built on concepts of

relational personhood, autonomy, justice, solidarity

• Attend to procedural ethics appropriate for public health