El efecto de la identidad social en la acción colectiva

Having extensively reviewed the bigger picture of the public health ethics debate, it is now important to show how this thesis may be able to offer insights into the study of ethical problems, how these problems are conceptualized in decision-making and resolved during response actions. Studying three key areas (human behavior, environment and technicality) can have greater effects on understanding planning and response actions in terms of how ethical problems arise and are resolved. The purpose of the conceptual framework proposed

for this thesis is to assist study of the role of ethics of planning and response. It also remains a departure point in discussing the analytical framework or Proactive Decision-Making (PDM) developed in the thesis. Contextual Public Health Ethics (CPHE) is the underpinning conceptual framework for this thesis. I am attempting to locate an appropriate line of reasoning for resolving ethical dilemmas, particularly in under-resourced countries in Africa where this debate is dormant. Muller (2001) has suggested that public health decisions, although not simple to map out, must be acceptable and proven to resolve inconsistent public health actions. Simply rejecting or accepting ethical decisions, picking and choosing judgment without reasoning or locating what’s morally acceptable, is bad practice, although common in Africa. Generally, developing public health ethics in sub Saharan Africa is a progressively slow movement, crawling from evidence to action while hampered by the lack of infrastructure and specialized ethical practitioners. Despite this slow progress, the level of public health ethics currently being practiced emphasizes public interests above all else, even though this may cause injustice to others. The concept of Contextual Public Health Ethics, although its premise leans towards public interest, is useful to balance private interests by taking into consideration civil liberties, human rights, the ethics of prevention and social and political concepts. The proposed CPHE position is a compromise leading to consensus: its aims are to balance public and private ethical expectations within the ideas of public health ethics.

According to this approach, decision-making processes taking the form of reasoning and justification should not only consider the ethics advocated in public health medicine, but should be reasoned within the socio-cultural and political settings supported by facts and values of all concerned. This consensus approach is useful in informing fair decision-making as well as minimizing risks and maximizing benefits to the population. This concept strengthens public health in two ways. Firstly, it goes beyond the traditional ethical reasoning of balancing potential harm and maximizes potential benefits in public health through the use of laws (social order), moral theories and policies that are agreed upon. This approach promotes dialogue between public and private individuals, and strengthens understanding of moral theories to expand and improve technical performance through consolidated ethics.

Secondly, by identifying ethical problems thoroughly in terms of how they are caused and the way they are resolved, it gives us the opportunity to adjust the various interactions such as environmental, technical and behavioral determinants necessary to control and manage the effects of ethical problems. The framework consists of four elements: moral theories, the

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Key influence in policymaking (behavioral, technical and societal).

Ethical Issues

concept of public health ethics and bioethics, triangular determinates (human behavior, environment and technicality) and performance and action strategies.

According to the framework presented below, an assessment of decision-making and response actions in public health should begin with an analysis of moral theories; i.e. a review of rules of conduct needed to frame an ethical argument for moral action. Ethical problems and dilemmas should be determined within the context of public health and medicine. This process is further facilitated by three key determinants: behavioural (attitudes, values and motivation), technical (social order, policies, laws, skills, training, resources, leadership) and society (structure, culture, communities, NGOs, religion). Based on the various interactions, solving these problems demands collective approaches, such as those facilitated by the field of public health ethics and bioethics.

The conception being proposed here relies heavily on empirical evidence, public consultations and dialogue to facilitate a particular course of action. The framework provides the philosophical basis for ethical reasoning and prepares policymakers with knowledge and leadership to apply in their decision-making. The theoretical framework is adaptive, proactive and reflective meaning that policymakers should be flexible, active decision-makers, whose advocacy should be subjected back and forth to critical thinking when diagnosing and prescribing answers to ethical problems.

4.8.0. Towards a Proactive Decision-Making (PDM) Analytical Model for Public Health Public health is a fast growing interdisciplinary field drawing its practitioners from different backgrounds, such as business, science and engineering. Diversity in public health means that practitioners tackle problems with different perspectives and technical mindsets. Due to threats of infectious diseases, relevant decisions are made to manage and control the disease problem. In recent years a number of public health decision-making models have sprung up, with noticeable disagreement about the course of action or manner of resolving conflicting policies associated to infectious diseases. Analysis of such decision-making processes can be seen in the manner and type of actions that each practitioner takes to pursue their goals and interests. Decision-making is deeply fragmented because we do not have general analytical models that appraise and examine the determinants that drive both decisions and non decisions. According to Bachrach and Baratz (1963) non decisions occur and are observable if there is bias, limitation of scope and manipulation of a latent issue. It could be argued that

in such decisions (non decisions) outcomes often tend to be passive and normative, largely influenced by manipulating values, myths and political institutions. On another hand

“decision” as it were, should be actively informed by evidence and values as well as reasoning and judgment of reasonable outcomes. For a decision or non decision to be made, it must constitute certain characteristics within the equations, such as influence and power. For example, actors, organizations or decision-makers with sufficient power or resources can use such power or resources to dominate or achieve goals or manipulate and block the functioning of rules and procedures for decision-making or conflict resolution. In order to investigate decision-making processes that affect policymaking, policy implementation and policy outcomes must be understood, including factors that influence them. Explanations that focus on internal structures of policy formulation, such as power, influence, force and authority among decision-makers, play an important role in determining policy outcomes.

Policymaking takes place in institutions and organizations; as such it is important to study them. Furthermore, endogenous factors such as socio-economics, politics, evidence and norms have significant influence on decision-making.

To understand decisions and non decisions, a Proactive Decision-Making Model (PDM) is proposed and used as an analytical tool to study the various interactions in the decision-making processes. Figure 4 highlights factors that significantly influence the decision outcomes. One of the strengths of the analytical framework proposed here is to study and explain the key factors that influence decision-makers to make decisions or non decisions as they do. It also provides a way in which key decision-makers should view and tackle policy problems. It does this by elaborating on the causal chain and setting out the explanatory variables and how they interact to affect policy outcomes. Analysis of the explanatory variables (Figure 4) can help sort out the details of what is and what is not significant to study in this thesis. Most importantly, it begins to inform the design of the methodology, particularly how policymakers decide how PRPI should be implemented including how ethical issues should be perceived and resolved. Before moving on to briefly discuss the criteria of choosing this methodology, it is essential to clarify how the explanatory factors incorporated into the analytical framework affect policy decisions.

The starting point in investigating decisions and non decisions is to consider who the decision-makers or actors are. Decision-makers or actors’ refers to individuals or groups who decide about the course of action on a latent issue. In Chapter 1, I defined decision-makers as

a group of individuals who operate in institutions such as government or non-governmental organizations with influence or authority to determine policies at the local, regional or national level. Decision-makers play a mediating role and that is the centre of this methodology. This is the first step in the analysis as it begins to situate the key players involved in determining policy outcomes. It is also a departure point for methodological consideration for this study as it is able to give pointers towards key data sources for decision-making analysis and method. For example, as will be described in the next chapter, I was able to identify decision-makers as key actors and include them in the study analysis regardless of their power and influence in the decision-making process.

Figure 4: Analytical Framework

Legend:

Decision-makers can be studied to gain insight about their role-taking in decision-making and retrospectively study policy outcomes by which we can highlight various factors involved in the decision-making processes.

PROACTIVE

Non Decision (passive) Institutions,

Socio-economic and Politics

Evidence and Norms Power, Influence, Force and Authority

Decision (proactive)

Policy Outcome Decision Makers/Actors

Exogenous Variables

The next step is to understand the relevant power, influence, force and authority and how these characteristics might influence the decision-making process. For Bachrach and Baratz (1963) the concepts of power, influence, force and authority have different meanings and are of varying relevance. Bachrach and Baratz note that power and influence are used interchangeably and force and authority are neglected in the decision-making process.

The difficulty in distinguishing clearly between power and influence is further complicated by the fact that the two are often mutually reinforcing, that is, power frequently generates influence and vice versa (Bachrach and Baratz, 1963). According to Bierstedt (1974), influence is persuasive while power is coercive. In other words, we surrender voluntarily to influence while power demands compliance. To demonstrate and achieve power requires the connectedness of conflicting values between persons in the power relationship. In a power relationship it is the compliant that chooses what to do, while in a force relationship it is the actor that chooses the course of action. Force, like power, involves a conflict of values; but unlike power, these are non-rational and tend to be non-relational (Bachrach and Baratz, 1963). Force means the decrease or restriction of choices or social action of one person by another in a firmly ordered system. Authority, according to Weber (1946), refers to subordinate groups accepting commands from the superior groups. Like power, authority here is regarded as a relational concept: it is not that the superior group possesses authority, but that the subordinate group regards the superior group’s communication as authoritative (Bachrach and Baratz, 1963).

In this analytical framework institutions and organizations are important to investigate because of the impact they have on decision-making. It is necessary to examine institution-actor relationships at the international, national, regional and local level. Institution helps to define the standards and rules of operation. Institution can be formal, such as government departments and non governmental organizations, and informal, such as less organised individuals or groups. Institutions differ in the way they operate from one country to another due to the scope and domestic and foreign policy priorities. Due to the influence that institutions may have, it is important to go behind the scenes when identifying institutions, in order to analyze covert actor-institution relationships. And due to the nature and type of institution in terms of the influence they exert on policy outcomes, less organised groups are more likely to be missed out if equal attention is not paid. The assumption in this analytical framework is that the limited involvement or exclusion of certain institutions may influence

or change the dynamics of how a decision would have been made. This explains why some institutions at the local level in this thesis were included for study analysis despite being less organised.

This analytical framework also integrates the roles of politicians because politics cannot be excluded from any model of decision-making. Again this informed the study to the extent that politicians were included in the analysis. Politicians oversee the disaster and emergency preparedness which sits in the office of the president in both Ghana and Malawi. Thus it was appropriate to seek views of politicians on how disaster programmes are implemented, including the way they go about making policies on pandemic influenza. The other explanations included in the analytical framework, as indicated earlier, are socio economic factors. The relevance of analysing the social and economic aspects of decision-making is to provide estimates of expected gains or losses of such decisions and if necessary make trade-offs. Equally importantly, socio-economic assessment provides an opportunity for strategic decisions when social or economic resources are available and accessible to be integrated into the decision.

Norms have been incorporated in the analytical framework because in the decision-making process there are no established rules for predefined solutions. Indeed, norms may be shared beliefs about what is considered an appropriate behaviour in a given society and they guide collective actions. Norms can be legal, customary or informal and are in competition with each other at a given time because they co-exist and overlap. This provides the major source of conflict about what one should and should not do. The understanding of norms is crucial in balancing values with evidence and more importantly, it maintains social order.

Since decision-makers are mediating players in this analytical framework, it is important to study and analyze the existing processes of decision-making to gain insight and directions about how policymakers go about making decisions as they do. Table 1 below shows Mnemonic PROACTIVE i.e. Problem, Reframe, Objective, Alternatives, Consequences and chances, Trade-off, Integrate, Value and Explore or evaluate, which can be applied to any decision that is made. Using mnemonic PROACTIVE tool for decision-making and applying it retrospectively to policy outcomes, it is possible to highlight the nature of decisions or non decisions including factors that influence decision-makers in making decisions.

Table 1: Mnemonic PROACTIVE Decision-Making Tool (Hunink et al., 2001).

Step Type and perspective Tools

Step 1 PRO

P Problem Define problem What will happen if I do nothing? Visualise with consequences table, sketch, or scheme Is there a problem

R Reframe Reframe from multiple Consider perspectives of patient, physician, Communicate with those involved in the decision perspectives department, hospital, payer, society Consider the issue from their side

Understand their perspective

O Objective Focus on the objective Consider diagnostic certainty, medical Ask those involved “why” what’s the goal?

effectiveness, microeconomics, Distinguish means objective and fundamental objectives and macroeconomics, psychosocial, Reconcile opposite conflicts objectives

political, ethical, and philosophical aspects Step 2 ACT

A Alternatives Consider all relevant Wait and see, intervention, obtain information Logical and lateral thinking

alternatives Different combinations, sequences, and positivity Brainstorm before critiquing. Be active but know Criterion of diagnostic tests that you do not control the outcome

C Consequences Model the consequences Model disease and events Balance sheet Chances and estimate the chances Estimate the corresponding probabilities Decision tree

Connectedness Be aware of the connectedness of all things Bayesian probability revision

Chaos Life is a network on a boundary between Meta-analysis

order and chaos Markov, Monte Carlo, microsimulation models

T Trade-offs Identify and estimate value Value of the outcomes Balance sheet

trade-offs Life expectancy Meta analysis

Quality of life Utility assessment

Monetary costs Cost analysis

Step 3 IVE

I Integrate Integrate the evidence Qualitatively Balance sheet. Recognise the interwovenness of all things

and values Quantitatively Average out: calculate expected value

V Value Optimise expected value Maximise desirable outcomes Fold back: apply decision criterion to choose Minimise undesirable outcomes Multiattribute outcomes

E Explore Explore assumptions Evaluate variability One-way, two-way, three-way sensitivity analysis Evaluate Evaluate uncertainty Evaluate stochastic parameter, and model Probabilistic sensitivity analysis

Although the mnemonic PROACTIVE decision-making tool is used to make decisions, retrospectively it can be used to study the explicitness about the problem, objectives, trade-offs, evidence and values involved in the policy outcomes. The analytical framework, PDM, is informed by the elements in the Mnemonic PROACTIVE, for example, when studying the nature of decisions or non decisions that were made.

The criteria on which this analytical framework is applied to examine decisions are four-fold.

First, it is practical (non-normative) and able to narrate the facts as they are step by step, as illustrated in figure 4. The framework is not prescriptive or exhaustive thus it can be used to study decision-makers as individuals and policy outcomes at any stage of implementation.

Second, the framework is very flexible and simple. It does not promote specific issues of individual experts; rather it is open and transparent on the broad range of issues that it might be significant to map out in the analysis. Put simply, it is interdisciplinary. Thirdly, the framework facilitates comparative research and does this by including broad explanatory variables which apply to a range of decision-making processes in other sectors. Fourth, the variables incorporated in the framework are not directly linked to policy outcomes and as such heighten the explanatory power of the framework because it accounts for the differences in the effects of exogenous variables. In short, it can be generalizable. And finally, the analytical framework is operational and recognises the fact that making decisions is a complex task and it can be difficult to comprehend.

The mnemonic PROACTIVE (Table 1) developed by Hunink et al. (2001) typically describes the decision analysis to assist with comprehension of the problem. It begins to give insights into endogenous and exogenous variables and their impact on the decision outcomes. It does this by permitting the decision-makers or actors to divide the logical structure of a decision problem into its components so that it can be analyzed individually, and then recombine it systematically so as to suggest a decision (Hunink et al, 2001). From the point of operationality, mnemonic PROACTIVE is not the analytical framework. Mnemonic PROACTIVE is incorporated within the proposed analytical framework shown in figure 4 because it takes into account thorough thinking in the nature of decisions that are made and work their way up to address the decision-making problems and the multiple factors involved. Through this process, I have been able to answer general questions like: what makes a good decision; how would one tell whether a decision made by public health professionals is legitimate, and how could it be justified as a good decision?