Second, there does not seem to be a unitary or agreed-upon framework of public health ethics.
Rather, there are various different ethical approaches, sets of principles, or ethical frameworks within public health ethics which give the impression of a quagmire of loosely related ethical concepts rather than a clear and consistent ethical approach grounded in a systematic and coherent foundation. What should be included in a public health ethics framework seems controversial. Given this situation, it is not clear to me which public health ethics framework to choose out of the ones available, and what reasons one could ultimately give for one’s choice apart from arbitrary personal preference. Indeed, this issue seems to me to be a worthwhile topic of focus for a doctoral dissertation on its own!
Consider the following examples.
(1) Childress et al. (2002) formulate a set of 9 principles for public health ethics. It appears as if these are influenced by the B&C principlist approach: these principles are general guides, provide prima facie duties, can be in conflict with one another, and should be specified and weighed when applied in ethical analysis. They call these principles ‘general moral considerations’ (p. 171), and the 9 principles are:
- producing benefits;
- avoiding, preventing, and removing harms;
- utility (producing maximal balance of benefits over harms and other costs);
- distributing benefits and burdens fairly (distributive justice) and ensuring public participation;
- respecting autonomous choices, and liberty of action;
- protecting privacy and confidentiality;
- keeping promises and commitments;
- transparency (disclosing information, speaking honestly and truthfully); and - building and maintaining trust (Childress et al. 2002, p. 171-172).
The general method of ethical analysis seems similar to the method of B&C. These principles are applied to public health interventions and when in conflict weighed against each other. Five additional principles or conditions are stipulated to aid in weighing the principles and deciding which principle in a conflict to prioritize over another: effectiveness, proportionality, necessity, least infringement, and public justification (p. 173).
The trouble is, it is not clear where these principles exactly come from. What is the foundation of these principles? What grounds them? Why these principles, and not others? A variety of different ethical frameworks are mentioned throughout the paper. On page 171 the authors
153 describe the commitments of public health, including communal action and communal good, in what appears to set the stage for a Communitarian justification. Further down on page 171 they invoke the paradigm of casuistry as being “compatible with” and “indispensable” to their conception of public health ethics. On page 173 they invoke the concept of a “social contract”
and a “liberal, pluralistic democracy”. On page 174 they cite Norman Daniels, who is a known Rawlsian egalitarian. On page 175 they argue from Mill’s work in On Liberty. To complete the full circle, on page 176 they cite a human rights paradigm. The authors appeal to these different and conflicting ethical paradigms within the same overarching argument as if they are somehow related to one another, moving from one to the other almost unacknowledged. Serious conflicts between these different approaches are not addressed, and no systematic approach for how these different theories are reconciled is offered. But even more surprisingly, the 9 principles offered are not in any noticeable way based on these ethical frameworks or derived from these ethical frameworks. Instead, the authors write:
“We can establish the relevance of a set of these considerations in part by looking at the kinds of moral appeals that public health agents make in deliberating about and justifying their actions as well as at debates about moral issues in public health” (p. 171).
So then, the 9 principles are derived from the “moral appeals” that public health agents make during the course of their work, and from debates on specific public health issues. It is not shown how this is done. It is also not shown what then provides normative grounding for these principles. It appears as if the authors imagine that simply because public health officials generally appear to appeal to principles of this sort, they enjoy binding normative grounding.
Interestingly, the authors appear to be somewhat aware of these deficiencies, as they write:
“The terrain of public health ethics includes a loose set of general concepts and norms that are variously called values, principles, or rules – that are arguably relevant to public health. Public health ethics, in part, involves ongoing efforts to specify and to assign weights to these general practices, and actions, in order to provide concrete moral guidance” (p. 171).
Thus, I find in the paper by Childress et al. (2002) not a coherent and adequately grounded ethical framework for analysis to the same extent as can be found in the principlism of B&C.
Rather, this seems to be an attempt at a starting point to draw out some important themes within public health ethics.
(2) Kass (2001) attempts to provide an ethics framework for public health. Like the Childress et al. article, she describes public health as focusing on the health of populations, and not individuals. She describes the communal nature of public health, collective communal actions leading to improved health for the entire community, and describes the particular role of the government in delivering public health. She then stipulates the need for an ethical framework for public health, distinct from medical ethics: public health institutions and governments can exercise a lot of power and consequently a code of ethics functioning of as a code of restraint is
154 important. “A code to preserve fairly… the negative rights of citizens to non-interference” (p.
1777). In her argument she cites various components and requirements of such a framework – the need to include “positive rights”, “affirmative obligations to improve the public’s health, and arguably, to reduce social inequities”, and the “social justice functions of public health” (p. 1777).
From this foundation, she proceeds to develop a 6-step framework for public health ethics, containing the following components (p. 1777-1781):
- What are the public health goals of the proposed program?
- How effective is the program in achieving its stated goals?
- What are the known or potential burdens of the program?
- Can burdens be minimized? Are there alternative approaches?
- Is the program implemented fairly?
- How can the benefits and burdens of a program be fairly balanced?
This framework is described as an “analytic tool” (p. 1777) which can be used to analyze the ethical implications of specific interventions and public health programs. According to this framework, a public health intervention has to adhere to all of these different elements in order to be ethical. First, it should be clear what the goals of the program are, how the program improves the health of the public, and to whom the benefits accrue. Second, it should be demonstrated to what extent the program can reach the stated goals. Third, risk for harms should be identified. The majority of such harms, she argues, include risk to confidentiality, risks to liberty and self-determination, and risks to justice if only certain groups are targeted by interventions (p. 1779). She does not here consider physical harms that may result from public health interventions. Fourth, consideration should be given to modifying programs to minimize the harms identified in step three. Fifth, the program should distribute benefits and burdens fairly, using principles of distributive justice. Initially she does not state a specific theory of justice when considering a fair distribution of benefits and burdens. But when she comes to a second argument, considering whether public health has a role in addressing existing societal inequities, she cites the theory of justice of John Rawls, and argues that justice requires society to help the least well-off. She does acknowledge that this theory of justice is not supported by all philosophers. Sixth, if a program is such that there is clear public health benefit that outweighs the burdens, the program should go forward. She acknowledges that citizens would disagree on how benefits and burdens are to be balanced, and therefore fair procedures should be in place to address such disagreements. This could include societal discussion on public health programs, including avenues such as public hearings to encourage the inclusion of minority views.
This framework is evidently very different from the framework in the Childress et al. article, yet starts off with similar assumptions regarding the nature of public health, its Communitarian commitments, and the role of government in public health practice. Once again a variety of ethical approaches are invoked to provide ethical grounding for the framework and norms elicited, without it being clear how different and conflicting ethical approaches are related to one
155 another. The ethical framework for public health that is presented provides a tool with six questions to which every public health intervention must adhere. There is some role for individual liberty or autonomy, the violation of which is considered a potential harm of public health interventions. In the balancing section in question six, it is mentioned that disagreements about benefits vs. burdens have to be settled by public discourse, without it being clear what framework can be used to settle such conflicts between ethical goals. For example, is one dissenter to a public health program enough to invalidate the program? Or can the majority overrule a dissenter and force compliance with the program? The provided framework does not provide a clear avenue for resolution of this tension, which is a central tension in public health in general, and in vaccination programs in particular.
(3) Gostin and Gostin (2009) considers the tension between individual autonomy and the public good. They state that they consider the problem using a Millian framework. In this article they argue for a hard form of paternalism in public health, arguing that public health interventions aimed at limiting the autonomy of individuals for their own good can be tolerated. Examples of the kind of interventions they have in mind are laws that prohibit smoking, laws that enforce helmet use for motorcycle riders, and regulations that combat obesity. Laws of this kind can be shown, they argue, to improve the overall health of the population. Since public health focuses on the health of the public and is communal in nature, and does not focus on individuals, infringements on autonomy that promote the overall good and wellbeing of the population can be justified.
Apart from using different ethical theories in their process of justification in a typical smorgasbord way, there is another serious objection to the entire overarching argument in this paper. Gostin and Gostin do not seem to realize the degree to which their argument engages in value-imposition, and underestimates the nature of value-pluralism in contemporary societies.
Contemporary societies contain various different conceptions of the good life, and an important precept in such societies is the idea that people should have the freedom to seek their own conception of the good as long as the same freedom is extended to others. In contrast with this, Gostin and Gostin argue that personal choices are the leading causes of death and disability in society, and that benign paternalism therefore have a valid role in society. Gostin and Gostin state that as opposed to various subjective conceptions of the good, the aim of public health is
“posivistic and objective” (p. 218). This represents a gross misunderstanding of the value-based assumptions that inform public health interventions. The Gostin and Gostin line of argument would actively engage public health officials and the government in choosing conceptions of the good on behalf of members of society, and justifies this by stating that its own conception of the good is the ‘objective’, preferable, and value-neutral one. But this flies in the face of respecting the values of other people and value pluralism. For example, let us consider their example of motorcycle helmets. Gostin and Gostin argue that many lives can be saved by paternalistic motorcycle laws (p. 217). Take now a fully informed motorcycle rider who hold independence and an active lifestyle in such high regard, that he would rather be dead than disabled or living in
156 a nursing home. Such a rider may know that his risk of dying is higher without a helmet, but thinks to himself that he would rather be dead than survive in a disabled state. Furthermore, he knows that his risk of injury and disability is quite high should he be in an accident and survive. Thus, he knowingly and in fully informed fashion refuses a helmet, because living in an injured or disabled state are unacceptable to him, given his values and his view of the good life. He would rather be dead than survive in a disabled state. Gostin and Gostin would impose on him their value of lives saved, and potentially force him into accepting a state of life that conflicts with his own values and goals. In other words, the “posivistic and objective” laws aimed at saving lives through enforcing helmet use overtly imposes a value judgment and a conception of the good life on the individual in the name of scientific objectivity.
Gostin and Gostin therefore advocate an approach to public health that is overtly paternalistic, where the public health official imposes value judgements on individuals in the name of improving the health of populations. This view faces serious objections, but I will not go into further detail here. Suffice it to say that this is highly controversial and contestable, and in my view indefensible. Be that as it may, the point I am trying to make in reviewing this article is to show how decidedly at odds this approach to public health ethics is with the approaches of Childress et al. and Kass. Yet, they all start off with the same set of assumptions regarding the goals and nature of public health, as well as the role of the government.
Having now considered three different public health ethics frameworks, it is clear that using a public health ethics framework for the analysis in this dissertation would present serious problems. The three presented frameworks conflict with one another, and it is not clear how the conflict can be resolved. There is no unified conception of what a public health ethics framework would look like. For example, the conception and application of individual autonomy differs radically in the frameworks I reviewed above. Which framework should therefore be used to analyze public health interventions where there is tension between individual freedom and the public good? To answer this question would be to engage in a body of work which would itself be a worthwhile focus of doctoral study.
Furthermore, it is not always clear how the different norms and frameworks are grounded. The argumentation does not always provide a clear connection between a stated public health ethics principle and the stated ethical framework. The authors also typically engage in an unsystematic use of conflicting ethical theories within the same argument, raising questions as to the validity and groundedness of conclusions.
I have demonstrated how B&C’s principlism is much better grounded, a more systematic approach, is based on widely shared moral judgments and therefore enjoys wider endorsement, and much more coherent than the controversy regarding public health ethics frameworks. Once again, B&C’s framework is preferable for the purposes of this dissertation than using a public health ethics framework.
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