Public Health Ethics: Key Concepts and Issues in Policy and Practice PDF
Preview Public Health Ethics: Key Concepts and Issues in Policy and Practice
Public Health Ethics Key Concepts and Issues in Policy and Practice Public Health Ethics Key Concepts and Issues in Policy and Practice Editedby AngusDawson CAMBRIDGE UNIVERSITY PRESS Cambridge,NewYork,Melbourne,Madrid,CapeTown, Singapore,SãoPaulo,Delhi,Tokyo,MexicoCity CambridgeUniversityPress TheEdinburghBuilding,CambridgeCB28RU,UK PublishedintheUnitedStatesofAmericaby CambridgeUniversityPress,NewYork www.cambridge.org Informationonthistitle:www.cambridge.org/9780521689366 #CambridgeUniversityPress2011 Thispublicationisincopyright.Subjecttostatutoryexception andtotheprovisionsofrelevantcollectivelicensingagreements, noreproductionofanypartmaytakeplacewithout thewrittenpermissionofCambridgeUniversityPress. Firstpublished2011 PrintedintheUnitedKingdomattheUniversityPress,Cambridge AcataloguerecordforthispublicationisavailablefromtheBritishLibrary LibraryofCongressCataloging-in-PublicationData PublicHealthEthics:KeyConceptsandIssuesinPolicyandPractice/ editedbyAngusDawson. p.cm Includesbibliographicalreferencesandindex. ISBN978-0-521-68936-6(pbk.) 1. Publichealth–Moralandethicalaspects. I. Dawson,Angus. RA427.25.P82852011 362.1–dc22 2010050335 ISBN978-0-521-68936-6Paperback CambridgeUniversityPresshasnoresponsibilityforthepersistenceor accuracyofURLsforexternalorthird-partyinternetwebsitesreferredto inthispublication,anddoesnotguaranteethatanycontentonsuch websitesis,orwillremain,accurateorappropriate. Everyefforthasbeenmadeinpreparingthisbooktoprovideaccurateand up-to-dateinformationwhichisinaccordwithacceptedstandardsand practiceatthetimeofpublication.Althoughcasehistoriesaredrawnfrom actualcases,everyefforthasbeenmadetodisguisetheidentitiesofthe individualsinvolved.Nevertheless,theauthors,editorsandpublisherscan makenowarrantiesthattheinformationcontainedhereinistotallyfree fromerror,notleastbecauseclinicalstandardsareconstantlychanging throughresearchandregulation.Theauthors,editorsandpublishers thereforedisclaimallliabilityfordirectorconsequentialdamages resultingfromtheuseofmaterialcontainedinthisbook.Readersare stronglyadvisedtopaycarefulattentiontoinformationprovidedbythe manufacturerofanydrugsorequipmentthattheyplantouse. Contents List of contributors vi Preface vii Acknowledgements viii Section 1 – Concepts 8 Vaccination ethics 143 Angus Dawson 1 Resetting the parameters: public 9 Environment, ethics and public health as the foundation for public health ethics 1 health:the climate change dilemma 154 Angus Dawson Anthony Kessel and Carolyn Stephens 2 Health,disease and the goal of publichealth 20 10 Publichealthresearchethics:isnon- exploitation the new principlefor Bengt Brülde population-based research 3 Selective reproduction, eugenics ethics? 174 and public health 48 John McMillan StephenWilkinson 11 Equity and population health: 4 Risk and precaution 67 toward a broader bioethics StephenJohn agenda 191 Norman Daniels Section 2 – Issues 12 Health inequities 211 5 Smoking, health andethics 85 James Wilson RichardAshcroft 6 Infectious diseasecontrol 100 MarcelVerweij Index 231 7 Populationscreening 118 AinsleyJ. Newson v Contributors Richard Ashcroft John McMillan Queen Mary, University of London, Flinders University,Adelaide, Australia London,UK Ainsley J. Newson BengtBrülde University of Bristol, Bristol, UK University of Gothenburg, Gothenburg, Carolyn Stephens Sweden London Schoolof Hygiene andTropical Norman Daniels Medicine, London, UK Harvard University, Boston, MA, USA Marcel Verweij Angus Dawson Utrecht University,Utrecht, Keele University,Staffordshire, UK the Netherlands Stephen John Stephen Wilkinson Cambridge University, Cambridge,UK Keele University,Staffordshire, UK AnthonyKessel James Wilson London Schoolof Hygiene andTropical University CollegeLondon, London, UK Medicine, London, UK vi Preface Thisbookservestointroduceanumberofcentralconceptsandkeyissuesinpublichealth ethics.Eachchapteriswrittenbyanexpertinthefieldandtheyseektobothintroduceand discuss critically at least some of the relevant literature related to their topic or theme. However, this book is not merely a textbook, as each chapter also seeks to advance (or in some cases re-frame) academic debate and practical reflection upon these topics in public health.Thisbookwillbeofinteresttoeveryoneworkinginpublichealthandrelatedfields, policy makers, as well as students in philosophy, ethics, public health ethics, medicine, public health and critical socialscience. vii Acknowledgements First, I would like to extend my warmest thanks to the many colleagues and friends that contributed their chapters to this collection of papers. Public health ethics is a relatively young discipline but the explosion of high-quality activity in this area in recent years has beenextraordinary.Iamverygratefulthatmanyofthebestmindsworkingonthesetopics were able tocontributesome oftheirwork to this volume. Second, I would like to thank everyone at Cambridge University Press who made this collectionpossible.Theirpatience,supportandexpertisehaveallbeenexemplary.Particu- lar thanks are due to NickDunton. Third, I would like to thank Melissa Williams, Ross Upshur and all at the Centre for EthicsandtheJointCentreforBioethics,forprovidingtheopportunitytospendtimeatthe University of Toronto and completework on the manuscript. Fourth,IwouldliketothankTrevorKingandBevSykesfortheirhelpinpreparingthe manuscript for publication. Finally, I would like to thank the editor of the Hastings Center Report and Wiley for theirgenerosityingrantingpermissiontore-publishmaterialthathadpreviouslyappeared. Chapter 8 is a revised and extended version of: Dawson, A. (2007) Vaccination ethics. In Principles of Health Care Ethics, 2nd edn, ed. R. Ashcroft, D. Dawson, H. Draper and J. McMillan. Chichester: Wiley and Chapter 11 is a very slightly modified version of: Daniels, N. (2006) Equity and population health: toward a broader bioethics agenda, HastingsCenterReport,36(4): 22–35. Angus Dawson viii Concepts Section1 Resetting the parameters Chapter 1 Public health as the foundation for public health ethics AngusDawson Introduction In this chapter I introduce a number of different approaches to public health ethics. However, Idothisinadeliberatelyprovocativeway.Iarguethatweneedarevolutionary, rather than evolutionary, approach to the development of public health ethics: in other words,weoughttoresettheparametersthatframethisareaofappliedethics.Iattemptto argue for this conclusion in the three sections of this chapter. First, I outline and defend what I consider to be a necessary condition to be met by any adequate theory of public health ethics. Second, I suggest what I call the traditional liberal approach, currently dominant in much medical ethics, fails to meet this condition because of the primacy it accords the idea of non-interference. I also suggest that various proposed alternatives, although offering some welcome broadening to this traditional liberal position, ultimately remainrestrictedbytheirimplicitorexplicitacceptanceoftheparameterssetbytheliberal approach.Third,IbrieflyoutlinearangeofareaswhereIarguethatfutureworkoughtto be directed as a means of developing a sufficiently rich account of public health ethics: a substantiveaccountthatmeetsmycondition.Isuggestthatsuchanaccountmustaccepta viewofhumaninterestsasintrinsicallysocial.Myprimaryfocusinthischapterisageneral argumentinfavourofthere-orientationofthefieldofpublichealthethics.Idonotdefend anyparticulartheoreticalperspective,beyondageneraldefenceofwhatIterm‘substantive’ accounts ofpublichealth ethics. I begin this discussion with the observation that if you approach public health from the perspective of much contemporary medical ethics, many public health policies and activitiesarelikelytobeviewedasethicallydubious.Thisisforanumberofreasonsbut will include the following: public health’s primary focus on populations rather than individuals; public health’s assumptions about necessary features of the human good; and a broader focus on other values beside non-interference. Consider just a few examples of core public health activities: cancer screening programmes are designed to reduce the number of cases in a given population, through the early discovery of asymptomatic cases. This focus might mean that informed consent and individual decision making are less of a priority than in some other areas of health care. Most preventive vaccination programmes seek to reduce the risk of individuals being infected with harmful diseases, through the creation and maintenance of a population effect called herd immunity. Such programmes aim to maximize participation because if PublicHealthEthics,ed.AngusDawson.PublishedbyCambridgeUniversityPress.#Cambridge UniversityPress2011. 1 2 Section1:Concepts insufficient individuals contribute, then this important protection cannot be achieved. A healthy environment with adequate sanitation, clean water and good air quality requires the coordinated activity of the whole community, through the day-to-day action of relevant civil or public agencies. This may impose significant cost on some industries and individuals. Health promotion can seek to change people’s preferences in relation to issues such as smoking, exercise and food choices, with the aim of reducing thechronicdiseaseburdeninapopulationthroughthepromotionofhealthierlifestyles. Many public health research activities are focused on populations, where epidemi- ological work to determine risk factors for disease may require the analysis of personal health information without the consent of individuals. Preparing for and responding to public health emergencies may require infrastructure for disease surveillance and legal structures to compel behaviour and seize property (in at least some circumstances). Health inequities are the result of many different socio-economic determinants and can often be addressed only through structural and societal level policy initiatives (that may in turn restrict or negate individual choice). If the currently dominant views in contemporary medical ethics are applied to these publichealthactivitiesthereisadangerthatsuchroutinepublichealthactionswillbeseen tobewronglyprioritizingpopulationoverindividualinterests.Onepossibleresponseisto acceptthiscritiqueandarguethatmuchpublichealthactivityisactuallyunethicalbecause it fails to prioritize individuals and their choices, as well as the moral principles that have evolvedwithinthefieldofmedicalethics toprotecttheseconsiderationssuchasinformed consentandpatientconfidentiality.However,analternativeapproachistoarguethatpublic healthisavitallyimportantactivityandthatitsendsarelegitimateandcanonlybeattained through such population-level interventions. On this view, the ‘problem’, assuming it is one,lieswiththeperspectivederivedfromtraditionalmedicalethics,notwithpublichealth practice itself. On this latter view, it is certainly possible for public health actions to be unethical, but the mere fact that they do not easily fit within a medical ethics framework does not make them unethical; and we certainly have no a-priori reason to hold public health to be intrinsically unethical. In this chapter, I argue that we face an important dilemma.Eitherweexplicitlyaccepttheconsequencesofourliberalframework(anddamn muchroutinepublichealthpractice)orwechoosetore-setourparametersandrethinkour ethical theories, thereby ensuring that public health activities and their justification move closertothecoreofethics.InthischapterIarguethatitistimeforustomovetowardsthe latter view. Anecessaryconditionforanyadequateaccount ofpublichealthethics In any clash between a chosen moral theory and public health practice and policy we have no reason to assume that it is the practice or policy that is problematic rather than the theory. In this section I will argue that we ought to accept a necessary condition for something being an adequate theoretical perspective in relation to public health, and that this condition ought to be applied as a filter in choosing an appropriate ethical theory for public health. I will call this condition the nature of public health condition. Ihavesuggestedthatmeetingthisconditionisanecessaryfeatureofanadequatetheory. What this means is not that we can rule out those moral views that fail to meet it, but that the consequences of embracing any view that does not meet the condition is likely
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