Presentación del modelo

The purpose of any decision-making models is to assist in the comprehension of problems by empowering decision-makers to make a choice as to which course of action is the most appropriate. Most of the decision-making frameworks that were reviewed in this thesis seem, at first, to be the appropriate frameworks to use in analysing how ethical issues are perceived and resolved. But, informed by the specific research questions in this thesis, most of the decision-making frameworks were dismissed as an analytical tool because they were weak. A considerable number of decision-making models are concerned and recognize ethics as a domain in itself; that is, a set of concepts and principles upon which to identify, establish and evaluate an ethical problem. For example, most were not concerned with establishing the relationship between variables such as planning and response, and ethical issues; even among the ethical models, most were not concerned with individual and situational roles to posit ethical positions. Trevino’s ethical model, for example, attempts to capture the combination of both the individual and the situation variables to explain and predict ethical decision-making behaviour (Trevino et al., 1986). Trevino’s decision-decision-making is, however, purely theoretical and designed to guide future business ethics.

Similarly, other decision models, such as Farrell and Gresham, Hunt and Vitell, and Dubindky and Loken, focus on specific ethical issues in marketing (Ford and Richardson, 1994). Those advanced by Rest (1986) and Jones (1991) are the only models that offer a theory of individual ethical decision-making that can be applied to other contexts and settings and have frequently been used in health care. However, these ethical decision-making models are rarely used in public health because they are not analytic in nature. Although not developed for use in public health, they do provide enough ethical discussion essential for studying, recognizing and resolving an ethical issue. The idea of these models is to ensure practitioners act ethically as individuals while making society as a whole ethical in the way it treats everyone⁷⁴. There is a great deal of grounds for concern that whatever we do may have consequences for the welfare of others. Unfortunately, we cannot always agree merely through verbal agreement, or even establish some sort of ethical principles upon which all of us could act and accomplish our moral ends.

74 http://www.scu.edu/ethics-center/ The The Markkula Center for Applied Ethics works with faculty, staff, students, community leaders, and the public to address ethical issues more effectively in teaching, research, and action (Accessed: April 22, 2013).

The fact that these measures are difficult to obtain because they are manifested in behaviour and intellectual skills led to Rest’s proposal to develop a framework to assist with ethical insights. Rest proposed a four component model for an individual’s ethical decision-making and behaviour. These include: recognizing the moral issue, making moral judgement, establishing moral intent and acting on moral concerns. Rest reiterates that success in one stage does not guarantee success in any other stages. The most important aspect in Rest’s model is that empirical research is emphasized as establishing the relationship between moral judgement and action. However, this type of model offered by Rest does not offer a simplistic means of ethical reasoning or an easy way of acquiring practical skills to analyze and evaluate situations of ethical perspectives.

Unlike most daily decisions, many substantial public health decisions involve considerable disagreements on the course of action and involve uncertainties and compromises. With such complex decisions, it can be extremely difficult to arrive at the best option, let alone justify it.

As such, decision-makers require better ways to make ethical public health decisions; they need some simplistic visual or written aids. The uncertainties surrounding the existing decision-making models led Daniels (2000) to improve the “accountability for reasonableness” model for public health decision-making. This model is deliberative and democratic in nature, focusing on justice issues in relation to the problem of health care in a priority setting. Accountability for reasonableness makes it possible to educate all stakeholders about the substance under deliberation on fair decisions under resource constraints (Daniels, 2000). Critiques of this model argue that it is not comprehensive enough to deal with the anticipated difficult questions of decision-making in public health that is concerned with non-priority setting situations. Friedman (2008) proposes a concept beyond accountability for reasonableness that promotes public involvement upon which reason is judged on its merits, such as consistency, plausibility and explanatory power, without any regard for its alleged sources of authority.

Other models in medicine appear to be quite comprehensive and tend to influence the level of ethical reasoning, but they are inadequate to inform an analytical framework for this thesis.

For example, the shared decision-making model involves patient-physician relationships. The model requires the physician to share medical knowledge and opinions with the patient, and the patient in return shares values and preferences with the physician. Applying this model in

developing countries where decision-making is paternalistic (doctors are still in charge of diagnosis, and prescription, without the participation of the patient) can prove challenging.

Building on models of decision-making processes, such as moral development by Rest (1986), an issue contingent model by Jones (1991), the health and human rights model by Mann et al. (1994) and the accountability for reasonableness model by Daniel (2000), could assist in developing an ethical framework. The ethical frameworks proposed by Canada, the UK and New Zealand, for example, draw on the accountability for reasonableness model when addressing issues of priority setting such as ensuring equitable, fair and cost-effective access when rationing limited resources to prevent and treat influenza. Accountability for reasonableness has obvious appeal to most ethical frameworks because it promotes four concepts such as relevance, publicity, revision and enforcement. In order to establish a fair process for priority settings, an accountability for reasonableness model has been at the heart of ethical framework development, for example, in the ethical frameworks for Canada, the UK and New Zealand. The ethical frameworks for Canada, the UK and New Zealand are based on principles for decision-making, although a deliberative and democratic process plays a bigger role. While principles need to be agreed upon beforehand within the ethical frameworks in order to effect a swift and reasonable resolution at the beginning of an influenza outbreak, the ethical principles are not very explicit in the frameworks. There ought to be a process of decision-making that guides principles in light of the many challenges associated with pandemic influenza. This thesis attempts to cover these gaps and I begin to do this by proposing a way of developing an ethical framework in Ghana and Malawi, as will be discussed in Chapter 9. This new way is not only limited to an accountability for reasonableness model but also utilises other concepts that I have reviewed such as moral development as proposed by Rest (1986). Decision-makers must appreciate moral authority and how this is essentially set through reasoning and judgement. Decision-makers can not only rely on agreement on various principles in solving ethical disputes in priority settings, but may also find it useful to rely on a clear process of reasoning and judgement in handling ethical problems.

Decision-makers must be able to recognise an ethical issue, be able to obtain facts about moral judgement, evaluate moral motivation or character, make a decision and, if possible, test this decision or reflect on the potential actions. The analytical framework discussed in

this chapter leads us to examine broad applicability and the needs across institutional, cultural norms and priority settings in public health. Proactive decision-making, as illustrated earlier in this chapter, is a problem solving analytic tool that can be used to appraise evidence and values, thereby allowing the decision-maker to make decisions explicitly so as to show what needs to be avoided or achieved.

4.9.0. Conclusion

The goal of this chapter was to develop a conceptual framework that can be used to investigate the ethics of planning for, and response to, pandemic influenza in sub Saharan Africa. This involved the consideration of moral philosophy upon which two dominant approaches of bioethics and public health ethics are derived and defined. Weber and Durkheim’s discussion of the notion of facts and values offers insights into historical debates and how problematic it is to bring together empirical and normative ethics. Moral theories have been considered, giving a glimpse into how policymakers in public health may consider making ethical decisions. Importantly, the discussion on moral theories attempted to explore the contributions to public health ethics. The review of bioethics and public health ethics revealed that disagreement exists between these paradigms in solving moral problems relating to pandemic influenza where individuals and the public alike are affected.

Having also reviewed empirical research on the ethical problems associated with pandemic influenza, it becomes clear that there is little empirical research investigating ethical problems in Africa. This chapter proposes that one way of studying ethical problems and the controversies between bioethics and public health, is to engage them on a level of reflective equilibrium. A contextual public health ethics as a theoretical framework and a proactive model of decision-making as an analytical framework have been proposed to guide and give insights into how public health professionals actually pursue and resolve practical problems of pandemic influenza. The Contextual Public Health Ethics is a useful concept that balances private and public interests by taking into consideration the civil liberties, human rights, ethics of prevention, social and political concepts.

The contribution of the chapter is the realisation that PDM is an appropriate analytical tool in bridging public policy, theory and practice. This is useful for exploring how public health professionals try to solve the ethical problems in a pandemic, since this tool is open-minded and applies deliberative and empirical actions to a range of identified problems. In the

proactive model, decision-makers invoke issues that are later discussed alone and agreed under fair terms. The chapter also facilitates transparency about reasoning that all can eventually agree to, if relevant. The above framework is applied to Chapter 6 of this thesis to examine the planning for, and responses to, pandemic influenza in Malawi and Ghana. It is then applied to Chapter 7 to study how policymakers identify, perceive and resolve ethical problems. This conceptual framework is applied to the role of decision-making in ethical reasoning and justification in Chapter 8.

CHAPTER 5: METHODOLOGY

5.1.0. Introduction

This chapter describes the strategy used to address the research questions set out in Chapter 1.

It considers what type of data is best to inform the study and how such data is acquired and analyzed. It will be argued that using qualitative methodology involving interviews and case studies is appropriate for gaining insights into the questions that this thesis poses. As will be shown, the chosen methodology and method not only deal adequately with the research questions concerned, but also contribute to the entire process and focus of studying Ethics of Planning for, and Response to, Pandemic Influenza (EPRPI). According to Silverman (2001), when conducting qualitative empirical studies, the research process must constitute a theory, hypothesis, methodology and method. Drawing on these four basic concepts, it is possible to make sense of the data that researchers’ collect, either to test hypothesis and theory, or simply to use the data to develop a tentative hypothesis or theory. As indicated earlier, this study is not concerned with developing theory; rather it is interested in examining the exploratory concepts using specific data.

In order to address the research questions of this thesis, the study design must be clearly defined in terms of its protocols and procedures. Chapter 4 outlined the theoretical and analytical framework, particularly how it benefits the methodology. Based on the theoretical framework, Contextual Public Health Ethics (CPHE), and the analytical tool, Proactive Decision-Making (PDM) analysis, provided enough methodological details to understand decisions and explore ethical issues in a dynamic sense. The conceptual analysis paid attention to the context of controversies and how these emerge and are resolved in public health. As discussed in Chapter 4, the theoretical framework in part explains the social phenomenon in studying ethics of PRPI. The analytical tool, PDM, provides methodological considerations for this study. PDM was used to study the various interactions in the decision-making processes. The explanatory factors that influence policy outcomes were able to point me towards key data sources and methods. Analytical considerations examined, such as internal structures of policy formulation including institutions, norms, power, influence, force and authority, guided what type of data to collect, who to recruit, and when to alter questions or define emerging themes. The guiding assumptions in the study, which are reviewed in public health literature, are that firstly, good planning leads to better responses (although this requires critical reasoning and

justification as well as consideration of ethics) and secondly, that effective response to pandemic influenza depends on preparation prior to the pandemic outbreak.

While the research questions seek to examine what policymakers considers as ethical problems and how they are identified and resolved in public health, the intention in this chapter is not solely to test hypotheses, but rather to scrutinize closely the unexplored ethical issues in public health. An interpretive (qualitative) study is the most appropriate way of uncovering or deconstructing the meanings of a phenomenon.

The research design used in this thesis does two things: it explains how ethical issues emerge (explanation) and why they are resolved in the manner they are (interpretation). As such, the present study may be compared with that of Rogers (2004), a public health qualitative study that sought not only to test a theory or hypothesis of causality of ethical issues but also explored how ethical issues in public health settings are resolved. It is not a requisite in qualitative research studies to have a specific hypothesis, unlike theories, which should be developed during the early stages of research. For Silverman (2001), hypothesis testing in qualitative studies, although assessed by its validity or truth, is not a general approach to studying a research topic. Ballinger (2006) also asserts that the qualitative research may require data for testing the hypothesis but it is not restricted to this model.