Upload
silas-copeland
View
217
Download
0
Tags:
Embed Size (px)
Citation preview
Public Health:The Need for a New Ethic
Nuala Kenny OC, MD, FRCP(C)Francoise Baylis PhD
Department of BioethicsSusan Sherwin PhD
Department of Philosophy
DALHOUSIE UNIVERSITY Halifax, NS
The Issue
• Health care with its focus on individual patient benefit has dominated the policy agenda since the 1960’s– Clinical ethics
• Public health has been neglected– Neglect of public health ethics
• We have a ‘window of opportunity’
Wake Up Calls re PH
• Emerging infectious diseases e.g. Ebola(1977), legionnaires(1977), HIV/AIDS (1983), variant CJD (1996)
• Re-emergence of diseases like TB
• Water-Walkerton (2000)/ Battleford(2001)
• Risk of bioterrorism such as anthrax (2001)
• Chronic illness ‘epidemic’, environment
• SARS (2002-2003)-Naylor Report
Impending Crises and Emergency-Preparedness
Pandemic
• Pandemic and other emergency preparedness/response issues finally galvanized action on public health– In Canada
– Elsewhere
Pandemic Ethics-early recognition
• U of T– Singer et al, 2003 lessons from SARS
– Stand on Guard…2005• Issues: civil liberties, privacy, duty of car (patients &
workers),credit for research, patent protection
• Kotalik– Plans should be “…instruments for building mutual
trust and solidarity at such a time that will likely present a major challenge to our societies”
Canadian Plan-2004
• Protect and promote the public’s health
• Ensure equity and distributive justice
• Respect the inherent dignity of all persons
• Use least restrictive means
• Optimize the risk/benefit ratio
• Work with transparency and accountability
International Pandemic Ethics
• Over 37 national plans have been identified (uscher-Pines et al, 2007)
• WHO
• US
• New Zealand
Our Analysis of The ‘Problem’
• Inordinate focus on pandemic and emergency preparedness not full range of PH (cart before the horse!)
• Inordinate dependence on individualistic bioethical principles originally developed for research and clinical ethics (particular before the general)
Principles of Bioethics(Beauchamp & Childress)
• Respect for autonomy
• Beneficence
• Non-maleficence
• Justice
Traditional autonomy• Promotes personal values
• Concerned with competence and knowledge of agent
• Enhanced when free of “outside influences”
• Best captured by informed consent
• Individual judgment of benefit/risk/harm
Justice
• Neglected Principle– Generally focused on non-discrimination
• Distributive justice-sharing in material resources
• Social justice-sharing in power, voice
• Restorative justice-repairing/reconciling for past injustice
Our Challenge
• To develop an ethic for public health appropriate to its nature and all core functions
• Public health broadly or narrowly understood?
• Ethics as inherent to public health (not imposed from without)
Traditional Aims of Public Health
• Protect & enhance the health status of the population
• Reduce health inequalities (inequities)
Functions of Public Health
• Health promotion
• Health protection
• Disease and injury prevention
• Population health assessment
• *Disease and risk surveillance
• *Disaster and emergency response
Traditional Focus of PH
• Modifying conditions leading to disability and premature death
• Populations and communities
• Reducing health inequalities
• Health differences that are modifiable
• The most vulnerable
• Collaborative action & citizen engagement
Duty and Public* Health Policy
• Safety and protection of the public from harm
• Maintenance of public trust• Promotion of the public/common good• Clinician duty and risk
– *public meaning populations/communities– *public meaning collective interventions
Jurisdictional Issues
• Constitutionally, public health is provincial
• Practically, public health services are municipal
• New and emerging threats cross all borders
• Lack of clarity re jurisdiction was a major problem in the SARS epidemic
An Ethic for Public Health
• What conception of autonomy? • The common good?• The public interest?• Benefit/Harm/Risk judgments
– Who? On what basis?
• How ought we understand justice in public health?
Public Health Ethics
• A growing body of general ethicswork:– D Beauchamp, Childress et al, Kass, Callahan
& Jennings, Upshur, Dawson & Verweij etc.– A new Journal of Public Health Ethics– PHAC identification of the need to identify
“Foundational Issues in Public Health Ethics”
– Social justice and public health: Anand et al, Gostin & Powers, Powers & Faden, Uscher-Pines et al, the Bellagio group
So…….
• We need a ‘new’ more comprehensive and coherent ethic for public health
• An ethic that identifies substantive and procedural values and principles
• An ethic intentionally reflecting the commitment of public health to– Promoting the health of the community– The reduction of health inequities
A Relational Ethic for Public Health
• Relational autonomy
• Social justice
• Relational solidarity
Reject individualistic ethics
• Account for ways in which individuals are embedded within communities
• Interests of individuals and communities are interconnected
• Promote positive (relational) account to address these realities
Relational autonomy
• Judgments about autonomy must reflect on range and nature of choices on offer
• Differences in social location may produce different range of options
Social Justice
• “Social justice is the foundational moral justification for the social institution of public health” Powers & Faden, 2006
Social justice
• Distributive justice: focus on fair distribution of quantifiable benefits and burdens among individuals
• Social justice: fair access to social goods such as rights, opportunities, power, and self respect; focus on groups as well as individuals (Young)
Relational solidarity
• We need a fully inclusive concept
• The meaning of solidarity is found within public health
• It must reflect that we are not all equally situated or affected by public health concerns and policies
Relational solidarity
• Mutual (not equal) vulnerability
• Motivation for committing to hard work of solidarity
• Need to attend to social justice in pursuing solidarity to achieve goals of public health
Procedural Ethics
• Inclusive
• Transparent
• Precaution
• Subsidiarity
Conclusions
• Make visible the role of public health in promoting public goods
• Focus on relations among humans
• Develop a relational ethic– Built on concepts of
relational personhood, autonomy, justice, solidarity
• Attend to procedural ethics appropriate for public health