Challenges in the Ethics of Public Health Peter L. Monette, Ph.D. November 24, 2004 The views expressed in this prese

1. Challenges in the Ethics of Public Health Peter L. Monette, Ph.D. November 24, 2004 The views expressed in this presentation are those of the author only and do not necessarily reflect those of Health Canada or the Government of Canada

2. Overview What is ethics? What is public health ethics? Framework for public health ethics Public health ethics and bioethics Challenges in public health ethics. Key Messages

3. What is ethics? The study of the good life and how to achieve it. Not ethics watchdog focusing on blame and wrongdoing Not a set of rules and regulations Relate to �ethics� in general. It is increasingly popular to talk ethics because of what are considered by many to be unethical behaviour. Think about Martha Stewart, Enron, sponsorship scandal. But thinking about ethics also includes good actions�we�re not talking saints here�but ordinary people doing ordinary things. Most people pay their taxes, etc. These are ethical actions. You don�t need a phd to do ethics, but it helps in being coherent and consistent! Relate to �ethics� in general. It is increasingly popular to talk ethics because of what are considered by many to be unethical behaviour. Think about Martha Stewart, Enron, sponsorship scandal. But thinking about ethics also includes good actions�we�re not talking saints here�but ordinary people doing ordinary things. Most people pay their taxes, etc. These are ethical actions. You don�t need a phd to do ethics, but it helps in being coherent and consistent!

4. Ethics Imagination What kind of a world do we want to create, to live and work in. Ethics is essentially about human creation; discovering what kind of a world we want and then trying to set up the necessary conditions for it to emerge. Ethics is not the exclusive realm of experts. Ethics analysis is a skill and can be developed. But, we are all called to be ethical. Visioning. Ethics is about visioning, seeing a better way of doing things for better results guided by values such as justice, fairness, health, etc.. Eg., the role of playrights, literature and movies in encouraging, motivating us to imagine a better world. Involves expanding horizons, working with the uncomfortable, Ethics is not the exclusive realm of experts. Ethics analysis is a skill and can be developed. But, we are all called to be ethical. Visioning. Ethics is about visioning, seeing a better way of doing things for better results guided by values such as justice, fairness, health, etc.. Eg., the role of playrights, literature and movies in encouraging, motivating us to imagine a better world. Involves expanding horizons, working with the uncomfortable,

5. Three Realms of Ethics Personal ethics, The individual ethical perspective often influenced by one�s religion and society. Professional ethics, Business ethics, nursing ethics, medical ethics, etc. Social ethics The study of the good of social institutions as they condition the fulfilment of individual desires. The key insight here is that we can fulfil some individual desires only via social cooperation. A handy distinction to help guide our discussion today. Not a hard and fast separation. But the intent is to distinguish the different types of value (v1, v2 and v3). V3. We need to reflect on the social institutions and their interconnectedness in order to judge whether they are contributing to the flourishing of human living. In ph ethics, this is expressed in the global level, for example, and the interconnections of societies (WHO). We see this expressed in the various levels of society: Local, Regional, Provincial, Federal, International. Focus on social ethics via the three fold distinction above. What kind of ethical framework can we use?A handy distinction to help guide our discussion today. Not a hard and fast separation. But the intent is to distinguish the different types of value (v1, v2 and v3). V3. We need to reflect on the social institutions and their interconnectedness in order to judge whether they are contributing to the flourishing of human living. In ph ethics, this is expressed in the global level, for example, and the interconnections of societies (WHO). We see this expressed in the various levels of society: Local, Regional, Provincial, Federal, International. Focus on social ethics via the three fold distinction above. What kind of ethical framework can we use?

6. What is public health ethics? The study of how public health activities and interventions contribute to the social good. Beyond determinants of health to the making of a healthy society. PH contributing to a better world; recurring themes in ph literature; Justice, fairness, healthy living, recovery, I�m going to come back to �beyond the determinants of health� What do I mean? I�ll be talking about some foundational issues in the ethics of public health; not so much abut specific ethical issues such as obescity, global health, genetics, nanotechnology, etc..PH contributing to a better world; recurring themes in ph literature; Justice, fairness, healthy living, recovery, I�m going to come back to �beyond the determinants of health� What do I mean? I�ll be talking about some foundational issues in the ethics of public health; not so much abut specific ethical issues such as obescity, global health, genetics, nanotechnology, etc..

7. Recurring Themes in Public Health Justice Equity Fairness Healthy living Recovery Rational Paternalism Some recurring ethical themes in ph literature. Familiar to all ph professionals. I�m going to come back to the idea of rational paternalism, but we can talk about this issue in more detail. The basic idea is that the public health challenge is to integrate a social perspective into a worldview which does not anticipate that the individual owes anything to society; other than tolerance and indifference.Some recurring ethical themes in ph literature. Familiar to all ph professionals. I�m going to come back to the idea of rational paternalism, but we can talk about this issue in more detail. The basic idea is that the public health challenge is to integrate a social perspective into a worldview which does not anticipate that the individual owes anything to society; other than tolerance and indifference.

8. Public Health Ethics: Current State Public health professionals have tended not to reflect on the ethical dimensions of their work. Perhaps because the values of public health activities were assumed to be valid. But in a pluralistic society this can no longer be taken for granted. Not a lot of literature on public health ethics; a coupe of books, about 20 articles or so. On point number 2 see John Last�s comments. But, public health professionals may be too busy to do ethics? Ethics requirement at CCD Ottawa Charter for Health Promotion Ethics code at APHA None in CPHA or OHPA The HIV AIDS pandemic: This key insight here is that the HIV AIDS pandemic is not an event that affects only a segment of society; an social enclave/the gay community, but affects all of society�in multiple ways.eg., think of the creative loss. Virtually all professionals have or will have to continue to articulate a professional ethics perspective, public health may be an integration of distinct professional perspectives. Not a lot of literature on public health ethics; a coupe of books, about 20 articles or so. On point number 2 see John Last�s comments. But, public health professionals may be too busy to do ethics? Ethics requirement at CCD Ottawa Charter for Health Promotion Ethics code at APHA None in CPHA or OHPA The HIV AIDS pandemic: This key insight here is that the HIV AIDS pandemic is not an event that affects only a segment of society; an social enclave/the gay community, but affects all of society�in multiple ways.eg., think of the creative loss. Virtually all professionals have or will have to continue to articulate a professional ethics perspective, public health may be an integration of distinct professional perspectives.

9. Public Health Ethics Framework Some have suggested that there is no coherent and comprehensive ethical framework to guide public health decision making and interventions If this is so, it will negatively affect collaboration and networking If this is so, then this is an added challenge for new developments in ph in Canada which are tending toward increased networking and collaboration. Without an ethical framework established at the same time that the collaboration is being worked out, is there a danger that inconsistencies will emerge that may negatively affect the level of cooperation, decision-making and subsequent interventions? Where have people turned to for help? Traditional bioethics.If this is so, then this is an added challenge for new developments in ph in Canada which are tending toward increased networking and collaboration. Without an ethical framework established at the same time that the collaboration is being worked out, is there a danger that inconsistencies will emerge that may negatively affect the level of cooperation, decision-making and subsequent interventions? Where have people turned to for help? Traditional bioethics.

10. Bioethics: Not the Right Fit Why traditional bioethics has not been helpful in providing guidance. Doctor-patient framework Emerging technologies and patient care Human rights for research subjects Tradition bioethics emerged in the 1960s because of moral dilemmas faced by the impact of new technologies in health care. It tends to focus on the relationship between physician and patient within the main values of an individualistic, rights-based, liberal society. Focus then is on individual and his/her ethics. Eg., end of life, treatment options, etc. It becomes obvious that since ph operates on the social level that traditional bioethics will not be that helpful. PHEthics understood from the social levelTradition bioethics emerged in the 1960s because of moral dilemmas faced by the impact of new technologies in health care. It tends to focus on the relationship between physician and patient within the main values of an individualistic, rights-based, liberal society. Focus then is on individual and his/her ethics. Eg., end of life, treatment options, etc. It becomes obvious that since ph operates on the social level that traditional bioethics will not be that helpful. PHEthics understood from the social level

11. Research Involving Humans The individual perspective dominates. The social or research interest should (usually) never take precedence over the interests of the research participant. Similarly in research involving humans, tragic events involving violations of basic rights raised questions about the ethical conduct of researchers. In 1995, the TCPS. The focus of the TCPS on individuals; while ph is focussed on society. Values such as human rights and dignity; autonomy via informed consent, truth telling, privacy and confidentiality; risk benefit ratios and importantly that research needs (social needs) should never overcome individual rights. See TCPS for the principle. May need a slide for this. ph turns the tableSimilarly in research involving humans, tragic events involving violations of basic rights raised questions about the ethical conduct of researchers. In 1995, the TCPS. The focus of the TCPS on individuals; while ph is focussed on society. Values such as human rights and dignity; autonomy via informed consent, truth telling, privacy and confidentiality; risk benefit ratios and importantly that research needs (social needs) should never overcome individual rights. See TCPS for the principle. May need a slide for this. ph turns the table

12. Bioethics/Public Health Ethics Bioethics Individual Society Public Health Ethics Society Individual

13. Nancy Kass: 5 Elements Reduce morbidity or mortality Based on sound science Burdens must be identified and minimized Program must be fair by minimizing existing injustices Fair procedures to determine acceptable burdens My interpretation of this article where the author identifies six questions Nancy Kass in AJPH, 2001, 91, 1776f �An Ethics Framework for Public Health� Kass� position remains essentially a Kantian one where the ends and means must be aligned. The fair procedures is a way to move her presentation forward. Ends = Population�s health and justice (distributive) Means= Science and Decision-making (justice as fairness) This is a framework to access the ethical validity of a Public Health Program or InterventionMy interpretation of this article where the author identifies six questions Nancy Kass in AJPH, 2001, 91, 1776f �An Ethics Framework for Public Health� Kass� position remains essentially a Kantian one where the ends and means must be aligned. The fair procedures is a way to move her presentation forward. Ends = Population�s health and justice (distributive) Means= Science and Decision-making (justice as fairness) This is a framework to access the ethical validity of a Public Health Program or Intervention

14. Public Health Ethics as Social Ethics Public health ethics is primarily concerned with social level not the individual level. Public health ethics needs to assess which activities and interventions contribute to the social good. There is a heavy responsibility to respond to society at the public, or population level, where interventions potentially affect many people, but which are often off set by complex social issues that affect specific individuals or groups of individuals or organizations. How can public health workers know when an intervention is good for society, ie that it is affective for its flourishing and therefore good? Even if in the short term there is negative consequences and/or there are limited resources available for an effective intervention?There is a heavy responsibility to respond to society at the public, or population level, where interventions potentially affect many people, but which are often off set by complex social issues that affect specific individuals or groups of individuals or organizations. How can public health workers know when an intervention is good for society, ie that it is affective for its flourishing and therefore good? Even if in the short term there is negative consequences and/or there are limited resources available for an effective intervention?

15. Good of Society The basic perspective of public health places society�s interest before the individual. It recognizes that the individual lives within the social context and The social context is a means for individuals to achieve private goals. Add the fact that the health of the society is good for the economics of a society. Eg., SARS ill health will negatively affect econoimcs; Common cold �costs� canadian economy $1billion per year.Add the fact that the health of the society is good for the economics of a society. Eg., SARS ill health will negatively affect econoimcs; Common cold �costs� canadian economy $1billion per year.

16. Living with and for others in just institutions Visioning, imagining public health activities and intervention which contribute to social good through the making of just institutions. Creating a healthy society through activities which integrate individual needs and rights with the social good. Slogan from Paul Riceour. Acts as a guide for a ph ethics framework; considerations of utility or consequences or virtue or procedures within this expression. Especially important as a reflection on ph institutions themselves and well as how ph interventions now need to work with other institutions to improve the health of society. Eg., working with financial institutions to improve the economy to relieve poverty and provide a condition for health living. The aim of ph ethics is a healthier society. Its activities contribute to this vision concretely. It�s important focus is on the just institutions which are, more and more, being recognized as conditions for the health of individuals. How can public health be an example of KEY CHALLENGE: Enhancing individual framework to include considerations of social good and having public health ethics integrate individual considerations. Thereby promoting a kind of rational paternalism where Slogan from Paul Riceour. Acts as a guide for a ph ethics framework; considerations of utility or consequences or virtue or procedures within this expression. Especially important as a reflection on ph institutions themselves and well as how ph interventions now need to work with other institutions to improve the health of society. Eg., working with financial institutions to improve the economy to relieve poverty and provide a condition for health living. The aim of ph ethics is a healthier society. Its activities contribute to this vision concretely. It�s important focus is on the just institutions which are, more and more, being recognized as conditions for the health of individuals. How can public health be an example of KEY CHALLENGE: Enhancing individual framework to include considerations of social good and having public health ethics integrate individual considerations. Thereby promoting a kind of rational paternalism where

17. Foundational Ethics Challenges Fear of Ethics Pluralism and Public Discourse Cooperation among Institutions Culture and Religion Ethics Education These are fundamental ethical issues which affect all specific issues in public health such as obesity, bioterrorism, genetic testing, nanotechnology, smoking, use of science in decision-making, genomics, global health, etc. These are fundamental ethical issues which affect all specific issues in public health such as obesity, bioterrorism, genetic testing, nanotechnology, smoking, use of science in decision-making, genomics, global health, etc.

18. Fear of Ethics Doing things differently Comfort in the past and in routine Losing control, sharing decision-making Dealing with people Dealing with politics Not having the skills for doing things a new way The opposite of these are the benefits of doing ethics analysis in public health also included are public trust building, improved practices and outcomes, professional ethos, public informing, reduced litigation (self-interest objective).The opposite of these are the benefits of doing ethics analysis in public health also included are public trust building, improved practices and outcomes, professional ethos, public informing, reduced litigation (self-interest objective).

19. Pluralism and Public Discourse Developing non-political forums for examining public health goals, activities and interventions in an open and transparent format. Not to establish blame Meaningful involvement Inform future action in the ongoing creation of a healthy society The aim of these forums is not to establish blame or accountability. They aim to establish whether and to what extend ph activities and interventions have contributed to the social good, the determinants of health, just institutions. The analysis aims to inform future action in the ongoing creation of a health society. examining public health schemes to determine how they are contributing to the flourishing of society; to revise them when they are not contributing, to design new schemes and remove destructive schemes. This is the foundation for a �weak� paternalism which collaborates with those potentially affected by public health interventions in order to develop cooperation action strategies that can be taken up by those affected as personal action strategies that contribute to the good society. These forums can provide for the condition that individuals can be responsible in acting within a civil society during a public health crisis or concern. Nonpolitical = Chief medical officier at arm�s length from political interference.The aim of these forums is not to establish blame or accountability. They aim to establish whether and to what extend ph activities and interventions have contributed to the social good, the determinants of health, just institutions. The analysis aims to inform future action in the ongoing creation of a health society. examining public health schemes to determine how they are contributing to the flourishing of society; to revise them when they are not contributing, to design new schemes and remove destructive schemes. This is the foundation for a �weak� paternalism which collaborates with those potentially affected by public health interventions in order to develop cooperation action strategies that can be taken up by those affected as personal action strategies that contribute to the good society. These forums can provide for the condition that individuals can be responsible in acting within a civil society during a public health crisis or concern. Nonpolitical = Chief medical officier at arm�s length from political interference.

20. Cooperation among Institutions Beyond the determinants of health to systems of influence Cultivating the attitudes and skills of cooperation, i.e., imagining beyond one�s scope of responsibilities, trust, risk-taking, conflict resolution. Working toward just institutions. Eg., of the Boston led removal program. Overarching perspective lacking; one arm of authorities not linked with other arms of authorities, so a worthwhile project failed. De-leading a home at $10,000 versus de-leading a child at $50,000. It is not enough for public health researchers, for example, to identify the interdependence of health and poverty. Public health professionals need to work with economic institutions to deal with poverty as a condition of the public health and the social good. These conversations require public health professional to engage in conversation with different perspective and languages, even customs and conventions, but it is a critical conversation which public health professionals can not ignore. The insights into the determinants of health alter public health professional interaction and place them in new terrain through partnerships with different institutions. These conversations require public health professional to develop different skill sets beyond medical and research competencies to the skills and virtues of discourse, conflict resolution, trust-building, etc. Post SARS we�ve heard a lot about this. Can often be the result of individual leaders and their personal ability to cooperate. But, the attitudes and skills can be learned and can become expected.Working toward just institutions. Eg., of the Boston led removal program. Overarching perspective lacking; one arm of authorities not linked with other arms of authorities, so a worthwhile project failed. De-leading a home at $10,000 versus de-leading a child at $50,000. It is not enough for public health researchers, for example, to identify the interdependence of health and poverty. Public health professionals need to work with economic institutions to deal with poverty as a condition of the public health and the social good. These conversations require public health professional to engage in conversation with different perspective and languages, even customs and conventions, but it is a critical conversation which public health professionals can not ignore. The insights into the determinants of health alter public health professional interaction and place them in new terrain through partnerships with different institutions. These conversations require public health professional to develop different skill sets beyond medical and research competencies to the skills and virtues of discourse, conflict resolution, trust-building, etc. Post SARS we�ve heard a lot about this. Can often be the result of individual leaders and their personal ability to cooperate. But, the attitudes and skills can be learned and can become expected.

21. Culture and Religion Sensitive to religious and cultural values (personal ethics) by asking: What conditions are necessary for individuals to make choices that benefit the social good? (rational paternalism) Personal ethics weaved with public health goals. �Weak� paternalism means being attentive to the personal values of society�s members many of which will bear directly on the potential outcome of a public health program. Eg., the cultural significance of raw fish for Japanese Canadians. Culture and religions values need to be weaved toward public health goals since these values often motivate individual action. Paternalism = authority taking responsibility for others lives and action Rational paternalism is presenting the reasons for public health activities which individuals can understand, judge and take as their own so that the individual makes the responsible choice and it is not the choice of public health authorities, therefore is not paternalism at all. So, the questions is What are the conditions for individuals to make choices in that benefit the social good? And what are society�s responsibilities in establishing these conditions?�Weak� paternalism means being attentive to the personal values of society�s members many of which will bear directly on the potential outcome of a public health program. Eg., the cultural significance of raw fish for Japanese Canadians. Culture and religions values need to be weaved toward public health goals since these values often motivate individual action. Paternalism = authority taking responsibility for others lives and action Rational paternalism is presenting the reasons for public health activities which individuals can understand, judge and take as their own so that the individual makes the responsible choice and it is not the choice of public health authorities, therefore is not paternalism at all. So, the questions is What are the conditions for individuals to make choices in that benefit the social good? And what are society�s responsibilities in establishing these conditions?

22. Ethics Education Ethics imagination and ethics education providing the tools for analysis and action. Public health professionals need to reflect more systematically on the ethical dimensions of their work and the impact their activities and interventions have on society. Providing good ethics education for public health professionals is often considered a foundational element to the future of public heath. Public health professionals need to reflect more systematically on the ethical dimension of their work and the impact their activities and interventions have on society. Change of professional attitude, perspective. Nonblaming nonjudgmental langugae in communicating with the public, eg., SARS was not in the end considered an Asian disease even though the link was definitely there at the beginning, eg., Chretien dinning at a chinese resturant. The HIV-AIDs example might be illustrative of a change of understanding, ie., perceiving the pandemic to be isolated to a social enclave of homosexuals to the full affect of the pandemic on society. It is not a gay-disease.Providing good ethics education for public health professionals is often considered a foundational element to the future of public heath. Public health professionals need to reflect more systematically on the ethical dimension of their work and the impact their activities and interventions have on society. Change of professional attitude, perspective. Nonblaming nonjudgmental langugae in communicating with the public, eg., SARS was not in the end considered an Asian disease even though the link was definitely there at the beginning, eg., Chretien dinning at a chinese resturant. The HIV-AIDs example might be illustrative of a change of understanding, ie., perceiving the pandemic to be isolated to a social enclave of homosexuals to the full affect of the pandemic on society. It is not a gay-disease.

23. Key Messages Ethics is about imagining a better world and cooperating with others to create it. Public health ethics is about living with and for others in just institutions. Public health professionals need to do more explicit reflection on the ethical dimensions of their work. In closing, summary, take home messages. Balancing individual rights and good of societyIn closing, summary, take home messages. Balancing individual rights and good of society

24. Challenges in the Ethics of Public Health Thank You The views expressed in this presentation are those of the author only and do not necessarily reflect those of Health Canada or the Government of Canada