The Morality of Setting the Public Health Agenda John Coggon & - - PowerPoint PPT Presentation

The Morality of Setting the Public Health Agenda John Coggon & A.M. Viens

Public Health Ethics and Law Research Group (PHEL) University of Southampton www.soton.ac.uk/phel

Wessex Public Health Network CPD Event 26th September, 2014

Aims

Overall to introduce: The fields of public health ethics and law

– Political, philosophical, and legal perspectives

Specific questions to explore:

• 1. What does ‘ethics’ mean in the context of public health?
• 2. How might values underpinning public health goals conflict with
• ther goals (e.g. economic goals, concerns for safeguarding

individual choice)?

• 3. What do ethical values in public health mean for the

implementation of different public health policies and practices?

Structure and Format

Structure Part I. Public Health and Public Health Ethics Part II. Ethics, Politics and Implementation Part III. General Reflections and Discussions Format Discursive and interactive throughout – ‘Mini-lectures’ – Small- and whole-group exercises and discussions (‘work points’)

Part I Public Health and Public Health Ethics

Studying Public Health Ethics

Be sceptical, and strip back ideas:

• “The public health community take it as an act of faith that

health must be society’s overarching value.”

• Suspicion of politicians
• “What is needed is a clear vision of a rationale for healthy

populations as a political priority.”

L.O. Gostin, Public Health Law: Power, Duty, Restraint (University of California Press, 2008), p. 7

What is Public Health?

• 1. The standard answer:

“[T]he science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts…, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.”

C-E A Winslow, “The Untilled Fields of Public Health,” (1920) Science 51:1306, 23-33, 30.

What is Public Health?

• 2. The philosophical answer:

“Firstly, …it makes sense to talk about public health as the state of the health of the public; that is, the health of the population as [a] whole, or a population’s ‘collective health’…”

Marcel Verweij and Angus Dawson, “The Meaning of ‘Public’ in ‘Public Health’,” in Angus Dawson and Marcel Verweij (eds.), Ethics, Prevention, and Public Health (Oxford University Press, 2007), p. 21.

What is Public Health?

• 2. The philosophical answer cont…:

“Secondly, in talking of ‘public health’ we often refer, not to the state of health of the public, but to a practice or set of interventions aiming to protect the health of the public. The latter use is clear in most definitions, e.g. ‘what we, as a society do…’ or ‘…through organised community efforts’. These interventions are in some way organised either by public institutions or they are carried out through collective effort”.

What is Public Health?

• 3. The complicated answer: The Seven ‘Faces’ of Public Health

Public Health as:

1) Political tool 5) Blind benefit/harm 2) Government business 6) Conjoined beneficiaries 3) Social infrastructure 7) Population health 4) Professional enterprise/endeavour

John Coggon, What Makes Health Public? A Critical Evaluation of Moral, Legal, and Political Claims in Public Health (Cambridge University Press, 2012), chapter 3.

Public Health as a Political Tool

• metimes ‘public health’ is taken to describe a social mission or theory,

and is thereby cited as the basis of a political imperative to act in certain ways to guarantee people’s good health. This idea is often expressed through the common law maxim salus populi suprema lex, which maintains that the health of the community is the highest law. E.g., “Health in all policies” movement – not merely the recognition that health is determined to a large extent by factors outside the health area but that health is a political imperative to be pursued across all areas of political control.

Public Health as Government Business

• me people use public health to denote the government’s

responsibility for protecting health. This may be limited just to the role

• f the Department of Health or Public Health England. Alternatively, it

may extend across all governmental action that might bear on health, from road safety to agricultural policy to town-planning to advertising standards. E.g., think of different Departments’ duties discussed in R (N) v SSH; R (E) v Nottinghamshire Healthcare NHS Trust (2009) EWCA Civ 795 Rampton smokers case)

Public Health as the Social Infrastructure

n some instances, public health is conceived more widely, to encompass both governmental and non-governmental responsibilities that are assumed for health. This could include, for example, voluntary measures taken by supermarkets to use a ‘traffic light’ labelling system

• n food products.

E.g., Public health responsibility deals – collaborative approach between government and industry to tackling the challenges caused by lifestyle choices, such as alcohol labeling and responsible drinking initiatives and traffic light system on food products.

Public Health as a Professional Enterprise

Public health may refer to a profession, defined by its members’ competences or expertise. E.g., UK Faculty of Public Health (FPH) On such a view, is public health whatever the FPH says it is?

Public Health as Blind Benefit/Harm

Many ‘public health interventions’ can be proven to have a net effect across a population whilst it is impossible at the individual level to identify to a certainty who has benefitted from them. In such instances, people talk of public health benefits or harms to describe a certain effect on health, even when it is not possible to identify this in individual detail. E.g., Rose’s prevention paradox – the use of statins to reduce cholestero

Public Health as Conjoined Beneficiaries

Some argue that ‘the public’ is not just a collection of individuals, but a community with special characteristics beyond being simply the sum

• f its members. In such cases, public health is used to emphasise that

‘no man is an island’, and individual health benefits and harms are a morally shared concern, so people have ethical reasons to care for their and others’ health. E.g., Vaccination as a demonstration of solidarity with others – herd immunity as a benefit up and above aggregated self-protection.

Public Health as the Population’s Health

Sometimes public health relates to health data within or between populations, either in aggregate or by reference to distribution. It is used in this way to present facts about health within a specified group

• f people.

I.e., public health as a descriptive and scientific enterprise – a collection

• f empirical claims about actual and relative health of groups.

Note: Descriptive vs. normative claims – on this view, nothing need follow from the descriptive fact that the prevalence of childhood

• besity continues to increase in the UK.

The Seven Faces of Public Health: The Upshot

‘Public health’ means lots of different things Sometimes it is descriptive, sometimes it is normative Sometimes it refers to measures that are aspiration, advisory or prescriptive The profession and practice of public health is multi-faceted and may entail a social mission – not everyone may agree what this mission is and there may be disagreement as to which values should be guiding this mission

Group Work Point 1: What do we mean by, and what do we try to ‘do’ with, the term ‘public health’?

Ethics within Public Health?

The place of ethics within public health is central, but there are different ways to consider how ethics plays a role in justifying and guiding practice. Ethics of Public Health Substantive ethical values (e.g., well-being, equity, stewardship) Procedural ethical values (e.g., transparency, accountability) Ethics in Public Health Specific issues or questions concerning what to do (e.g., who should get the limited supply of antivirals? Should we set a minimum price per unit of alcohol? Should we criminalise HIV transmission?)

Public Health Ethics

Bruce Jennings’ categorisations:

• Professional ethics
• Advocacy ethics
• Applied/Practical ethics
• Critical ethics

Bruce Jennings, “Frameworks for Ethics in Public Health,” Acta Bioethica (2003) IX:2, 165-176.

Jennings on Public Health Ethics

• 1. ‘Professional Ethics’: “the values and standards that have been

developed by the practitioners and leaders of a given profession

• ver a long period of time, and … those values most salient and

inherent in the profession itself.” But: is ‘public health’ really a single, unified profession? Are there other values that might get in the way or conflict with values of the public health profession, such as privacy, autonomy, economic goals, distributing benefits and burdens fairly?

Jennings on Public Health Ethics

• 2. ‘Advocacy ethics’: A characteristic of contemporary public health is

“less theoretical or academic than practical and adversarial.” But: public health ethics as advocacy “has little to calm and reassure those outside the field who may question the legitimacy of public health’s use of its governmental or social power.”

Jennings on Public Health Ethics

• 3. ‘Applied-’ or ‘Practical Ethics’: a more detached public health

ethics, which comes from without the profession and its history, and draws from abstract principle. But: there is a tendency for applied ethics only to relate to individualistic concerns. It thus suffers an inadequacy in dealing with collective concepts such as ‘the public’, ‘society’, and ‘the community’, or collective values such as ‘the common good’ or ‘the public interest’, which are all pertinent in discussion of public health

Jennings on Public Health Ethics

• 4. ‘Critical Ethics’: Critical public health ethics would be informed by

the history and practice of public health as a profession. But it would also, given a concern for applied ethics, draw from wider social values to inform understandings of the nature of moral problems that might be addressed through public health programmes. And in relation to advocacy ethics, Jennings’ critical ethics would require “the discussion of ethics and public health policy to be genuinely public or civic endeavors.”

Two Roles for Public Health Ethics?

• Philosophical ethics

– ‘Ivory tower’ stuff “What makes health public?”

• Practical ethics

– ‘Make the world a better place’ stuff “How can health be made public?”

“Public health law is the study of the legal powers and duties of the state, in collaboration with its partners… to ensure the conditions for people to be healthy…, and of the limitations on the power of the state to constrain for the common good the autonomy, privacy, liberty, proprietary, and other legally protected interests of individuals.”

Public Health Law vs. Public Health Ethics

L.O. Gostin, Public Health Law: Power, Duty, Restraint (University of California Press, 2008) p. 4.

Both public health law and public health ethics are normative enterprises. They are concerned with justifying why certain public health activity should be taken, who has obligations or responsibilities for protecting and promoting public health, etc. Both public health law and public health ethics encompass different values held by different world views – some values

• verlap, some conflict.

Public Health Law and Public Health Ethics

Politics and Public Health Ethics

In this context, our normative theory and ethical values must be able to speak to: – Political and social institutions – Populations – Mediation of disputes between ‘world views’ – The right and the good

Public Health: Neutral Science or Political Imperative?

Lawrence O. Gostin, ‘A Theory and Definition of Public Health Law,’ Journal of Health Care Law & Policy 10(2007): 1-12, 2:

“The public health community takes it as an act of faith that health must be society's

• verarching value. Yet politicians do not always see it that way, expressing preferences,

say, for highways, energy, and the military. The lack of political commitment to population health can be seen in relatively low public health expenditures. Public health professionals often distrust and shun politicians rather than engage them in dialogue about the importance of population health. What is needed is a clear vision

• f, and rationale for, healthy populations as a political priority.”

Think of the public health advocacy and activism encouraged by Tony Delamothe (BMJ), Martin McKee (LSHTM), etc.

Group Work Point 2: What does it mean to engage in public health ethics?

[Coffee!]

Part II Ethics, Politics and Implementation

Public Health Ethics as Political Theory

“Public health measures raise complex questions about the relationship between the state and individuals and organisations that are affected by its policies. They also raise questions about the duties that individuals have towards each other. A substantial body of literature in political philosophy examines these relationships of duties and entitlements…” “The central issue in public health is the extent to which it is acceptable for the state to establish policies that will influence population health.”

Nuffield Council on Bioethics, Public Health – Ethical Issues, (London, 2007), pp. xv and xvi

Public Health Ethics as Political Theory

“Public health measures raise complex questions about the relationship between the state and individuals and organisations that are affected by its policies. They also raise questions about the duties that individuals have towards each other. A substantial body of literature in political philosophy examines these relationships of duties and entitlements…” “The central issue in public health is the extent to which it is acceptable for the state to establish policies that will influence population health.”

Nuffield Council on Bioethics, Public Health – Ethical Issues, (London, 2007), pp. xv and xvi

Public Health Ethics as Political Theory

“Public health measures raise complex questions about the relationship between the state and individuals and organisations that are affected by its policies. They also raise questions about the duties that individuals have towards each other. A substantial body of literature in political philosophy examines these relationships of duties and entitlements…” “The central issue in public health is the extent to which it is acceptable for the state to establish policies that will influence population health.”

Nuffield Council on Bioethics, Public Health – Ethical Issues, (London, 2007), pp. xv and xvi

The ‘Start Point’ in Political Analysis

AN ANALYSTS’ HEALTH WARNING!!! Whatever political theory you work with, remember: Your ‘start point’ for a complete political theory will not necessarily be health! Don’t presume that you can derive ethically-defensible political imperatives if you begin with (public) health – you must know your political morality before you can know your public health ethics! Think about ‘political spectrum’ idea (with pinch of salt…)

BIG range of potential theories

Stewardship

Stewardship concerns the management or care of something or somebody. Stewardship, as an ethical or political value, embodies a set of obligations or responsibilities to manage or care for something/somebody in a particular way. Stewardship is a value often invoked in the health care or public health setting

World Health Organization, World Health Report 2000 (Geneva: WHO, 2000) Karen Jochelson, Nanny or Steward? – The Role of Government in Public Health (London: King’s Fund, 2005) Nuffield Council on Bioethics, Public Health: Ethical Issues (London: Nuffield Council, 2007)

Nuffield Council on Stewardship

The concept of ‘stewardship’ is intended to convey that liberal states have a duty to look after important needs of people individually and collectively. It emphasises the obligation of states to provide conditions that allow people to be healthy and, in particular, to take measures to reduce health inequalities. The stewardship-guided state recognises that a primary asset of a nation is its health: higher levels of health are associated with greater overall well-being and productivity.”

Nuffield Council of Bioethics, Public Health: Ethical Issues (2007), pp. xvi-xvii.

Stewardship’s ‘core characteristics’

Concerning goals, public health programmes should try to: *aim to reduce the risks of ill health that people might impose on each other; aim to reduce causes of ill health by regulations that ensure environmental conditions that sustain good health; pay special attention to the health of children and other vulnerable people; *promote health not only by providing information and advice, but also with programmes to help people to overcome addictions and other unhealthy behaviours; *aim to ensure that it is easy for people to lead a healthy life; ensure that people have appropriate access to medical services; and *aim to reduce unfair health inequalities

Nuffield Council of Bioethics, Public Health: Ethical Issues (2007), p. 26.

Stewardship’s ‘core characteristics’

In terms of constraints, such programmes should: *not attempt to coerce adults to lead healthy lives; minimise interventions that are introduced without the individual consent of those affected, or without procedural justice arrangements (such as democratic decision-making procedures) which provide adequate mandate; and *seek to minimise interventions that are perceived as unduly intrusive and in conflict with important personal values.

Nuffield Council of Bioethics, Public Health: Ethical Issues (2007), p. 26.

The ‘Intervention Ladder’

How could we use the concept of stewardship – including what it prescribes and constrains – to guide public health policy and practice? An intervention ladder can be used as a practical tool to think through a range

• f options available to government and policy makers about how to approach

the regulation of different public health issues. The intervention ladder would outline progressive steps regulation might take, where at the bottom of the ladder, the steward (i.e., the state) would regulate public health with an emphasis on individual freedom and responsibility, then gradually moving up the ladder the steward would employ more interventionist

• r coercive measures.

Nuffield Intervention Ladder

Source: World Health Organization, From Policy to Action [http://apps.who.int/adolescent/second-decade/section8/page5/from-policy-to-action.html]

Regulating Public Health: Intervention Ladder

Rung 1. Do nothing or simply monitor the current situation E.g., Community-based monitoring of health services Rung 2. Provide information: Inform and educate people E.g., Campaigns to encourage people to walk more or eat five portions of fruit and vegetables per day.

Nuffield Council of Bioethics, Public Health: Ethical Issues (2007), p. 42.

Regulating Public Health: Intervention Ladder

Rung 3. Enable choice: Enable to change behaviour E.g., by offering participation in an NHS ‘stop smoking’ programme, building cycle lanes, or providing free fruit in schools. Rung 4. Guide choice by changing the default: Make ‘healthier’ choice the default option E.g., in a restaurant, instead of providing chips as a standard side dish (with healthy options available), menus could be changed to provide a more healthy option as standard (with chips an option available).

Nuffield Council of Bioethics, Public Health: Ethical Issues (2007), p. 42.

Regulating Public Health: Intervention Ladder

Rung 5. Guide choices through incentives E.g., offering tax-breaks for the purchase of bicycles that are used as a means of travelling to work. Rung 6. Guide choice through disincentives E.g., through taxes on cigarettes, or by discouraging the use of cars in inner cities through charging schemes or limitations of parking spaces.

Nuffield Council of Bioethics, Public Health: Ethical Issues (2007), p. 42.

Regulating Public Health: Intervention Ladder

Rung 7. Restrict Choice: Regulate to restrict the options available E.g., removing unhealthy ingredients from foods, or unhealthy foods from shops or restaurants. Rung 8. Eliminate Choice: Regulate to eliminate choice entirely E.g., compulsory isolation of patients with a virulent infectious disease.

Nuffield Council of Bioethics, Public Health: Ethical Issues (2007), p. 42.

Group Work Point 3: Stewardship, politics and public health ethics

Part III General Reflections and Discussion

Public Health Ethics and Law

For more detail of our research and teaching in public health ethics and law, see the PHEL website: www.southampton.ac.uk/phel We are also organise general and bespoke continuing professional development and education programmes in pubic health ethics and law. For general enquiries, please contact: phel@soton.ac.uk For individual enquiries, please contact: John.Coggon@soton.ac.uk or A.M.Viens@soton.ac.uk