Public Health: The Need for a New Ethic Nuala Kenny OC, MD, FRCP(C) Francoise Baylis PhD Department of Bioethics Susan 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 ( )-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