Public health: ethical issues.

Abstract

Ethical discourse in medicine has been geared towards the typical clinical scenario of the individual patient encounter with the healthcare system. Over the years, as biotechnology made dramatic advances, the bioethical debates too, evolved to focus on the implications of research and technological innovation.1 In more recent years, public health has enjoyed a renaissance and as a result, its accompanying ethical dilemmas have been brought into the bioethical spotlight. The latest offering from the Nuffield Council on Bioethics, Public health: ethical issues, is therefore very timely and makes a substantial contribution to the emergent field of population level ethics. Broadly, the text is divided into two sections. In the first section, the authors explain the nature of public health and set the scene by summarizing some of the key perspectives that can be applied when considering ethical questions in public health. For example, importance of freedom from coercion, importance of minimizing harm to others, importance of protecting vulnerable populations, etc. In the second section, the authors contextualize these perspectives by situating them within four different scenarios or cases: infectious diseases; obesity; alcohol and tobacco and water fluoridation. In the first three chapters, after providing a comprehensive introduction to public health, the authors go on to articulate in greater detail the added complexities inherent to ethical decision making at the population level, including: the need to balance the conflicting interests of the individual with the community; implementation of preventive measures; redressing health inequalities and importantly the role of the state as the arbitrator of these actions. Borrowing from political theory, they outline a spectrum of ‘state-citizen’ relationships, ranging from libertarian to liberal through to collectivist and, although the discussion is far from exhaustive, the authors distil out for the reader the beliefs that lie at the hub of each of these schools of thought. Then, choosing the liberal state as a prototype of Western government, the authors propose an ethical framework that would be in keeping with the ideologies of such a state. However, this initial framework, outlined in chapter 2 under the heading ‘an initial liberal framework’, is then modified to both enable and entrust the state to undertake a more active role in ensuring health for its citizens. The authors go on to propose a modified liberal framework that would encompasses these added expectations and call this the ‘stewardship model’. Unlike the set of four principles that form the framework for clinical ethics (i.e. respect for autonomy, beneficence, non-maleficence and justice), the ‘stewardship model’ is presented as a set of guidelines addressing goals and constraints for public health programmes. This approach to ethical frameworks is not unprecedented in public health.2 It may be argued that because of the varied (and sometimes competing) interests of the individual, society and the state, guidelines that are developed to greater specification are more useful to public health than a code with a set of overarching principles. What is surprisingly lacking in this scene-setting is the lack of overt reference to the juxtaposition of the two key ethical theories (i.e. deontological and utilitarian) that inform public health debates. Although the authors discuss utilitarianism, they do not at any point contrast its principles with those of duty-based ethics. In chapter 3, the authors go on to introduce the ‘intervention ladder’—a tool for determining how interventionist a public health policy is. The higher the rung, the more intrusive the policy and, therefore, the stronger the justification needs to be for implementing it. Importantly, both here and elsewhere the authors emphasize that taking no action also entails an active decision and (depending on the situation) will require justification. In the subsequent chapters, we are presented with case studies that have been selected by the authors as areas within public health to which many of these debates are relevant. At the beginning of each chapter, the authors provide specific background information on the topic in question, laying out the pertinent facts, so that subsequent discussion is easily accessible to people who have no background in public health, medicine or ethics. For example, the authors’ explanation of vaccination, what it entails, pros and cons would be easily comprehensible to a non-specialist reader and provides the backdrop within which to situate the ethical issues that arise. For each topic the authors go on to talk about specific aspects of population level ethics that are of particular salience, incorporating into the discussion comments received as part of the consultative process. At the end of each chapter, the authors provide recommendations that would, by their reasoning, be appropriate to include in the po