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Sociologists and philosophers have traditionally held opposing views regarding the respective claims of empirical ethical research and normative claims. Social science research is

concerned with describing the world “as it is” (or how it is perceived to be) (Draper and Ives, 2007). Philosophy is traditionally concerned with how the world ought to be: it is essentially prescriptive, seeking to guide decisions and actions and to evaluate and analyze moral concepts (Draper and Ives, 2007). The two fields of study, described in this way, could be said to occupy the different worlds of what “is” and “ought” to be respectively (Draper and Ives, 2007). This dichotomy has also been mentioned within debates about sociological method as the fact/value distinction. Garrard and Wilkinson (2005) have discussed the importance of the fact/value distinction for understanding the nature and scope of enquiry into bioethics. Relating the field of bioethics to the well-known philosophical problem of deriving ethical conclusions from empirical premises, they note that ‘if we cannot derive ethical conclusions from them, the role of empirical data in bioethics appears suspect’

(Garrard and Wilkinson, 2005). However, this methodological impasse leads to a severe delimiting of the scope of bioethics, which becomes merely normative, speculative, and unable to draw conclusions from the objective conditions of social reality.

A useful way of approaching the problem of the fact/value distinction is by considering the different positions taken up by Max Weber and Émile Durkheim, two of the most important ethical thinkers within sociology. For Weber, statements of facts are one thing, statements of value are another, and any confusing of the two is not permissible (Dahrendorf, 1987).

Weber's ideas on facts and values not only considered developing the field of sociology but also how an ethical approach could progress in biomedicine. Weber was concerned with the possibility of a value-free science, his theory presuming a split between the “values” of political order that are beyond critical evaluation and the science of the structure of social reality that might be used as technical knowledge by politicians. In sharpening the issue of a

“value-free” science to this pragmatic point, Weber moved the debate beyond methodological arguments towards an order of relevance. He demanded that sociology attain the status of science because he wanted clarity about the world, but his inability to reconcile the claims of fact and value within a single method of social enquiry meant that his search for truth was cut short at the level of pragmatic action.⁶⁸ In the end, Weber did not feel the need to legitimise the study of society by establishing its credentials as a science, thus keeping values and facts separate.

68Weber’s biography at http://www.biography.com/people/max-weber-9526066 and his collected works at http://voegelinview.com/from-The-Collected-Works/max-weber-and-positivism-pt-1.html (Accessed: May 23, 2013).

For Durkheim, conversely, moral rules come from society and are thus amenable to scientific study, and they must be viewed as facts like other social facts. Durkheim (1953) tells us that society must be labelled as a collective being and viewed as a set of social facts since these have a different reality from the facts of natural science. Durkheim and Weber’s methods are useful as they enable a relationship between values and ethics that might relate to the developing field of sociology despite their origins in opposing principles. Adherence to facts by these theorists is usually praised and it is an assurance that empirical evidence in relation to ethics has not been entirely rejected by normative accounts. This makes it possible to derive ethical conclusions from the (contextual) facts of the social world.

This debate as to the possibility of ethics being derived from empirical observation continued, as is reflected in the historical development of medical ethics. In the twentieth century, different ways to examine ethical issues emerged. By the 1970s, some scholars sought to create a different kind of medical ethics to examine normative values; the new discourse of bioethics was the result. The term “bioethics” is believed to have been invented by Van Rensselaer Potter, a research oncologist at the University of Wisconsin, who published an article in 1970 entitled ‘Bioethics: the science of survival’ (Potter, 1970). This was later followed by his book Bioethics: Bridge to the Future (Potter, 1971). The earlier practice of bioethics was characterized a great deal by agreed moral arguments and a methodology that took the form of voting, as opposed to ethical analysis. It was only later that ethical theories became available for ethical analysis and judgment became concerned with issues like “who decides, when to decide and who benefits from the inadequate resources”. Despite the scope of ethical analysis and arguments, moral direction and critical moral reflection remained the centre of controversy. Bayer et al. (2004) suggest that methodological controversy arose because the emerging bioethics drew its principles from general rather than Hippocratic medical ethics. The rationale for situating bioethics within a general ethical paradigm was partly to enable the posing of questions of immediate social concern, such as; “can anyone do any good ethics without underlying theory”? and “what ethical theories are appropriate in ethical analysis”? However, other disagreements and conflicts in the methodology still lingered and no one seemed able to deal with them during the paradigm shift to bioethics.

Emerging infectious diseases in public health confronted bioethics with other concerns, another aspect that created moral heterogeneity in the field of bioethics. The fact that there were many concerns about the rights of individuals and the responsibilities of the state to

protect health, led to the emergence of the new field of public health ethics – a perspective this thesis is concerned with. Since the development of bioethics and public health ethics in the 1970s, adversarial relationships and tensions have existed between those concerned with issues of individual freedom (including autonomy and human rights) and those who emphasize the role of society and culture in establishing ethical conduct. Although individuals are competitive with one another for resources or status, it is important to remember that society is made up of individuals, thus ways of dealing with conflicts are embedded in institutions and organizations to which they belong. The problem, however, is the issue of legitimacy of control. Institutions may empower individuals but they do so in ways that are constrained by rules and sanctions. Weber is very clear that we should distinguish power constrained by law or other social practices from power that is exercised in a purely individual and arbitrary fashion. Through such rules and sanctions, institutions can empower individuals to exert control over resources and social functions and, by doing so, limit or deter social order and thus indirectly resolve ethical issues in general.

Bioethics and public health ethics are further discussed later in this chapter. Just as Max Weber and Émile Durkheim could not reach agreement, public health ethics and bioethics tend to secure moral considerations between individuals and population health with completely opposing claims. The presence of tension and disputes signify that conflicts among values arise in public health, where facts are considered to narrow the shortcomings of values that frequently appear. Even today, moral philosophers struggle to balance public health decisions between what is best for the individual and society as a whole. This is when empirical and normative ethics should come into play to guide ethical actions. However, these goals are being increasingly challenged by a number of factors, mostly those relying on empirical and normative accounts of ethical reasoning.

When laying out the debate between empirical and normative accounts, it is important to remember that philosophy can fundamentally aid and clarify values and views of reality: the study of philosophy is not simply an isolated endeavour, but rather one that attempts to make normative ideas clearer, in order to resolve or prevent disputes. The presence of philosophy is an important aspect for any sensible debate on ethics, although this is clearly disputed within the texts of empirical ethics. For Engelhardt (1986), empirical ethics are always to some extent derived from normative ethics, that is, within the realm of ideas and values brought forward to sketch a rational and consistent account of empirical answers. This, however, requires one to be a geographer of concepts and values, analysing and criticizing the

advantages and disadvantages of alternative projections and the mapping of concepts and values. This kind of undertaking is inherently philosophical; it is not one of empirical anthropology or sociology. Bioethics as an intellectual enterprise contributes towards the better understanding of controversies in a similar way to philosophy. It offers a better appreciation of our cultural context by encompassing analytic skills and a knowledge of the history of ideas (Engelhardt, 2011).

Empirical ethics is not particularly concerned with what is held to be the correct conduct in a particular society, or with determining what viewpoint is most credible to most people.

Rather, it endeavours to determine what reason should be; credited by impartial, unprejudiced, non-cultural biased reasoning, the only interest of this is consistency and the force of rational argument. This unprejudiced viewpoint can be fully achieved only through the goals of empirical research, which serve as a guide to tentative moral answers. There are numerous but often neglected relationships between normative and empirical ethics that provide unique answers to particular questions: both provide moral guidance, in the sense of giving instructions regarding the likely character of the moral world and the moral significance of choices within biomedicine. Similarly, the development of sociology led to an interest in ethical reasoning within empirical perspectives; for example, the assertion that empirical sociological research in bioethics should be focused on the ethics of research, the creation of moral boundaries, bioethics and social policy, and the bioethical imagination (De Vries, 2006). According to De Vries (2006), this passage offers practical models of co-operative work, where the strengths of each discipline are brought together to advance our understanding of bioethical issues and to move towards a more just and effective social policy.

Empirical ethics in a broader sense holds profound implications for moral philosophy and public policy. Today, it is increasingly being proposed that applied moral philosophy directing moral perspectives demands evidence-based information. However, embracing empirical evidence remains a slow and contested issue in bioethics because it has long been firmly based on normative theory. Yet empirical and normative ethics taken together allow for a deeper understanding of people’s interests, patterns of behaviour, and culture.

Moreover, it broadens the understanding of ethical concerns from an empirical perspective into people’s actual objectives. If empirical public health ethics and moral philosophy can be applied together to gain insights into the ethical issues of planning for, and response to,

pandemic influenza, then it is necessary to align this dissertation with that process. It is hoped that meaningful interpretation derived from empirical ethics, applied within the knowledge of normative ethics, can provide ethical solutions to problems encountered in public health pandemics. An ethical methodology that proceeds this way, supported by evidence of the nature of ethical issues, is likely to guide and clarify moral claims or ideas in a more satisfactory and effective way. For example, by using empirical evidence, moral theories will be applied intentionally and not in an exploratory or unconscious way. The other advantage is that the outcomes of moral acts can be assessed precisely, since these outcomes are validated.

4.2.0. Public Health and Public Health Ethics: Definitions and Conceptualizations One of the goals of this study is to identify the public health related dilemmas and emerging problems faced by policy-makers during the 2009 H1N1 pandemic influenza. To construct a complete picture of what ethical dilemmas or problems might mean in this context, an extensive analysis is needed. This entails defining public health and conceptualizing the ethics embraced in moral theories. A working definition of public health is therefore needed before dealing with the data-sets which form chapters 6-8. Public health is a contested concept with various definitions. However, one widely recognized definition comes from the World Health Organization (WHO); it defines public health as the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society and individuals (Wanless, 2004). Although the tenets of public health are to prevent health threats through good advice and the prevention of disease by concerted efforts, its goals have shifted towards a crowded intersection involving prevention strategies, health risks and health outcomes. The terminology of public health was first coined in the early part of the nineteenth century to distinguish communities and societies from individuals when promoting and protecting the population’s health.

In 1920, Winslow defined public health as:

“the science and the art of preventing disease, prolonging life and promoting physical health and efficiency through the organized community efforts for the sanitation of the environment, control of community infections, the education of the individuals in principles of personal hygiene, the organization of medical and nursing services for the early diagnosis and preventative treatment of diseases, and the development of social machinery which will

ensure to every individual in the communities a standard of living adequate for the maintenance of health” (Winslow, 1920).

Despite Winslow's definition of public health being outlined in 1920, its influence can still be seen in many of the recent accounts of public health. For example, the Acheson report (Acheson, 1988) and the Institute of Medicine (1988) subsequently embraced Winslow’s definition. What is peculiar in Winslow’s definition are the discussions about how public health is to be achieved; specifically, how things ought to be arranged to bring it about.

However, the noticeable difference between the definition of public health by Winslow and the revised versions articulated by the IOM and Acheson report are seen to be embedded within a more critical interpretation of the concept of public health.

The Institute of Medicine (IOM) redefined public health in 1988 as “public health is what we, as a society, do collectively to assure the conditions in which people can be healthy”. On the other hand, Acheson redefined it as “the science and art of preventing disease, prolonging life, and promoting health through the organized efforts of society”. This is the definition the WHO tends to use nowadays. The first definition seems to allow for the non-universal nature of the concept of ‘health’, and in this sense incorporates critical interpretations of health, while the second is normative taking for granted the (universal) concept of health in the manner of Winslow.

The normative dimension and debate about the definition of public health has not ended;

Lawrence Gostin has recently argued for a redefinition of public health. For Gostin (2010) public health is defined as a societal obligation to assure conditions for people’s health. In the same debate, Childress et al. (2002) also noted that public health is primarily concerned with the health of the entire population, rather than the health of individuals. Childress and his colleagues provide a list of features that emphasize the promotion of health and the prevention of disease and disability: the collection and use of epidemiological data;

population surveillance and other forms of empirical quantitative assessment; a recognition of the multidimensional nature of the determinants of health; and a focus on the complex interactions of many factors – biological, behavioral, social, and environmental – in developing effective interventions (Childress et al., 2002). This account given by Childress is an important one because it includes not only an account of the aims of public health, but also a focus on the entire population’s health and determinants of health, including a list of certain

public health methodologies. According to Mann et al. (1994), civil liberties and public health must be fundamentally linked in order to realize policy goals in a non-discriminatory manner.

The meaning of public health differs from place to place. The original concept of public health – the purpose of which constituted societal approaches to improving population health – has recently been applied to clinical medicine and focuses on the interest of the individual.

Public health is a derivative term that is population-based, meaning that it draws its evidence from population statistics (such as relative or attributable risks) rather than individual data entrenched in clinical medicine. The primary health care (PHC) approach of the Ottawa charter of 1978 is another good example which attempts to define public health through its ten key areas of preventive health (see appendix 2) (Tarimo and Webster, 1994). The major concern for the PHC which is entrenched in public health is to set priorities based on likely improvements in overall (not disease-specific) health in populations and population subgroups by conceptualizing prevention as a set of activities (Starfield et al., 2008).

However, these goals have become eroded and increasingly neglected amid emerging themes of globalization, trade, and foreign policy (Sambala et al., 2010).

Having given an overview of different public health definitions, it is now important to look at how public health ethics is construed. At this point, it is worth noting that the different definitions of each assume different understandings of the field in terms of methodologies and attitudes to concepts such as preventive medicine. Furthermore, the different meanings of public health have produced confusion in the development of a coherent public health ethical code. Thomas et al. (2002) have discussed the Code of Ethics in Public Health. The scope of public health changes over time under the influence of new paradigms, so the concept of public health ethics has been stretched beyond its initial definition. Not only has public health ethics become increasingly challenging for policymakers, but better approaches to public health ethics have evolved, further changing the concept of public health. Coughlin and Beauchamp (1996) define public health ethics as “the identification, analysis, and resolution of ethical problems arising in public health practice and research”. Public health ethics has completely different domains of interest compared to its counterpart “medical ethics”. Whilst public health attempts to deal with emerging and re-emerging communicable and non-communicable diseases, public health ethics seeks effective early warning systems and ways to deal with these problems before they worsen. Since public health ethics is a subfield of

public health and has recently been recognized as a subfield of bioethics too, Coughlin (2008) has argued for the inseparability of public health and public health ethics, demanding the interplay between population, health and the individual. Traditionally, public health and its ethics incorporate individuals and society within their analyses.

Whilst definitions of public health tend to emphasize communities, individuals remain an important part of their analyses. The professionals representing the field of public health medicine, such as epidemiologists, social scientists and psychologists, work with both individuals and communities towards well-defined goals of public health. Applying ethical considerations in this way remains problematic, especially for African professionals. For example, how do you decide who gets the limited vaccines when everyone needs them?

Whilst definitions of public health tend to emphasize communities, individuals remain an important part of their analyses. The professionals representing the field of public health medicine, such as epidemiologists, social scientists and psychologists, work with both individuals and communities towards well-defined goals of public health. Applying ethical considerations in this way remains problematic, especially for African professionals. For example, how do you decide who gets the limited vaccines when everyone needs them?