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 other 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 ometimes ‘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 ome people use public health to denote the government’s responsibility for protecting health. This may be limited just to the role of 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 on 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 of 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 of people. I.e., public health as a descriptive and scientific enterprise – a collection of 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 obesity 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 over 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.”
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