1. World Health Organization
9 June, 2018
WHO Training Manual
Ethics in epidemics, emergencies and disasters: Research, surveillance and patient care
Learning Objective 4.2
Discuss moral theories, and identify frameworks applicable
to research in emergencies
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2. Outline Major frameworks applicable to research
The pluralistic approach
Principles to justify coercion in public health
Comments and summary
Suggested time
0-15 (15 min)
16-25
(10 min)
26-55
(30 min)
56-60
(5 min)
Activity
Slide presentation of slides 2-5 and discussion
Slide presentation of slides 6-7
Slide presentation of slide 8 and discussion
Summary and conclusion
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3. Approaches to ethics in public policy
Utilitarianism—achieve the best outcome (in terms of aggregate human well-being—”utility”)
Libertarianism—respect individual liberty
Egalitarianism—promote equality (e.g., John Rawls, part of the “difference principle”: justice requires making those who are worst off as well off as possible)
Rights based theories—respect (human) rights
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4. Value Pluralism
Each of these approaches is presumably partly correct because the values they emphasize (utility, liberty, equality, rights) each matter.
But what should be done in cases when there is conflict between these values?
Presumably no one of these values should always trump all of the others (regardless of the degree to which the others are threatened)?
R/e 3rd point, it should be noted that even international human rights law acknowledges that human rights might not always be absolute—e.g., see Siracusa Principles.

5. Value Pluralism
Whenever a given policy/action would maximally promote all of these values, then it is obvious what should be done.
In cases of conflict between these values, we should aim to “strike a balance” between them.
But what is a principled way for making trade-offs between these values in cases of conflict?

6. Commonly proposed principles for the use of coercion in public health (emergencies):
Need for evidence
Least restrictive alternative
Proportionality
Equity
Minimally burdensome
Compensation
Due (legal) process—right of appeal
Democratic/transparent policy making
The idea here is that coercive measures (e.g., isolation/quarantine—or surveillance without consent) shouldn’t be used unless there is good reason to believe that they will be effective in achieving the public health goal in question. But, among other things, this raises questions about how much evidence is needed—and what should be done in (urgent) cases where evidence is lacking (e.g., in the case of a new pathogen for which there is limited information).
We should use the least restrictive measure necessary to achieve the public health goal in question. I.e., we should not resort to mandatory isolation/quarantine or surveillance without consent if voluntary measures would suffice (or be just as effective). This is from Siracusa Principles.
The idea here is that (because utility doesn’t trump autonomy/liberty/rights), we shouldn’t resort to coercion whenever this would have best (utility) outcome overall. We should only resort to coercion when the public health costs would otherwise be severe. But this raises the question of how great the utility stakes would need to be in order for coercion to be justified.
Such measures shouldn’t be used in a discriminatory manner. We should perhaps be most reluctant (in light of Rawls) to coerce (and thereby harm) those who are already worst off or especially vulnerable?
Analogous to 2, this might be called “the least harmful alternative”. The idea here is that those confined (for example) should be made comfortable and provided with basic necessities and so on. In the case of surveillance, we should minimize privacy violations as far as possible.
Perhaps those coerced should be compensated in return—as a matter of reciprocity. E.g. compensated for financial loss—or simply for having one’s liberty violated.
7 and 8 should be relatively obvious—but they raise questions about what the processes should be in practice—especially in conditions of urgency.
Should highlight how/that such a framework aims to strike a balance between values emphasised in slides 2-5—i.e., they aim to protect against severe public harms without riding roughshod over liberty/autonomy, equality, and rights. There are still many questions (to be discussed), however, about how these principles could or should actually be applied in practice.

7. Summary
All for moral theories (utilitarianism, egalitarianism, libertarianism, rights-based approaches) each prioritize different values.
To date, ethical frameworks developed to guide the conduct of public health activities have mainly focused on specific principles describing the conditions under which constraints on individual liberty (= coercion) might be justified.
However, questions about their adequacy, legitimacy, and implementability warrant further reflection.

8. Sources
Rawls J. A Theory of Justice. Harvard: 1971.
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9. Chapter author Acknowledgements
Selgelid, Michael J., Centre for Human Bioethics, Monash University, Clayton, Victoria, Australia
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