Finding Traction in Public Health Ethics: Reflections and Practical Resources

--Submitted by Michael Keeling and Olivier Bellefleur, National Collaborating Centre for Healthy Public Policy (NCCHPP)

We are fortunate enough to live in interesting times. We are also fortunate that there is not (or, we don’t think there is!) an app for sense making, for navigating the difficult terrain of our lives. And, amid the occasional charge that public health’s mission has crept into too many spaces, and the more-frequent charges of nanny-state-ism, collectively we in public health have a complex mandate, one which offers us challenges that show no signs, alas, of abating. So, we tackle the challenges, ideally with courage, rigour, respect and a spirit of collaboration, and we do our best to improve health and honour public health’s value(s) of social justice and equity, all in diverse and complex environments. There is no guarantee that we will succeed.

Broadly speaking, we set out to advance the values of public health. However, for any action, program, policy that we propose, we can and should rightly ask: “What makes this worth doing? What justifies this practice?” The question that underlies everything we do is an ethical question.

In what follows, we will describe some of the thinking that orients the National Collaborating Centre for Healthy Public Policy’s (NCCHPP’s) work in public health ethics. We will conclude with several links to guiding documents and practical resources that may help practitioners’ efforts to bring an ethical perspective into their work.

In varying degrees, there are several dimensions or types of consideration to which we may appeal in order to respond to the question: “Why?” All have ethical implications; none are value-neutral.

Of course, evidence of effectiveness is one such dimension. We have generally come to realize that while properly contextualized evidence is important and perhaps essential, it is surely not sufficient. Evidence itself is not value-free: there are important questions underlying the funding, production, and use of evidence.

We can also appeal to cost-effectiveness to inform our decisions. It may not be the most cost-effective option that we choose in the end, but taking this into consideration can help to inform whatever decision we do make.

We can also consider whether the community (or the affected communities, variously defined) would find this initiative acceptable, and whether the issue that we are addressing is judged to be sufficiently problematic to be considered a priority for support, both among various constituencies of citizens as well as at the political level.
 
In addition to those considerations, there are the underlying values to consider, whether we speak of the broader society, communities, the workplace, those embodied in policies and proposals, and individual practitioners’ own values, among others. Those values are not consistently defined, they are not uniformly held and they may be contested in various ways.
 
Among the diverse contexts found in the public health sector we find a vast range of goals, situations, populations, issues, professional standards, and approaches. This is reflected in some of the key areas of practice: clinical, research, advocacy, prevention, surveillance, promotion, communication, preparedness, population health, etc.

This diversity is reflected in the roles of practitioners. To sample just a few, consider: restaurant inspector, home visitor – neonatal home visiting program, epidemiologist, health equity consultant, health impact assessment specialist, nutritionist, school mental health promoter, medical officer of health, policy maker, public health nurse – home care program, GIS researcher – urban transport, health consultant – Indigenous youth centre, school nurse – vaccination programs. Consider how different the world might look from each of these perspectives.

We also see different levels of focus from the more micro-level of one on one relationships in a clinical context to the more macro-level of population-wide policy approaches and structural-level interventions.

Consider just one of the roles from the list above for a moment in order to illustrate the micro-macro issues embodied in a straightforward (if challenging) public health program. Consider the home visitor for a neonatal health program developed by a public health authority.

At first glance, the home visitor works one on one with families in order to support them, ultimately to help improve health outcomes for newborns through the provision of information, resources, and support to parents. In this role, however, the home visitor will often encounter families who are suffering from economic and social deprivation. So, the ground level worker is confronted by the effects (social and economic deprivation), the causes (inequalities/inequities in the social determinants of health), and the causes of the causes (macrosocial determinants that act to produce inequalities in the social determinants). He or she can think about prevention, policy, and how this situation arose in the first place while attempting to deal with the effects of poverty, and the effects of social inequalities, and the effects that issue from the macrosocial level, or, considered from a particular perspective, that issue from the political economy. S/he probably does not have the time or resources to work upstream. A health unit, a regional authority, a provincial ministry, do have mandates both to help to alleviate the effects and to focus more upstream to tackle the causes. Contained within the scope and mandate of one worker’s daily role in providing one on one consultation with families, we can find ethical issues relating to doing good for individuals, respecting individual autonomy, protecting confidentiality, balancing goods and harms, making judgments and trying to act in the best interest of parents and children.  At the workplace level we see issues of developing program goals, policies and guidance for home visitors in their roles, protecting workers from moral distress and burnout, distributive questions about the allocation of resources between upstream prevention and reacting to immediate downstream needs and by what criteria these are prioritized. At the policy level we can touch upon various broad areas of intervention such as healthy public policies affecting the social determinants of health (income, education, housing, Indigenous ancestry, and gender among others – see e.g., Mikkonen & Raphael, 2010) that have been shown to improve outcomes for individuals and families. And we can certainly also consider the broader societal structures that make things so: the political economy is the set of assumptions, practices, and relations of power constituting the air around us, the medium that influences individuals’ potential for flourishing (see, e.g., Mantoura & Morrison, 2016, for a discussion of different approaches for influencing health, from individual-level to political economy).

At whatever level from micro to macro that we consider, and whatever perspective tends to prevail according to professional role and workplace context, “practitioners are frequently faced with difficult situations in which they have to make decisions with explicitly moral dimensions and yet they receive little training in the area of ethics” (Schröder-Bäck et al., 2014, p. 9).

This diversity, complexity, and pervasiveness produce unique challenges for public health ethics. On the one hand, a culture that promotes an ethical perspective and ethical literacy among professionals is important: this applies to everyone, with the understanding that each will operate with different perspectives, skills and capacities. Their ethical perceptions may be more, or less, or differently, developed. On the other hand, it is challenging to find a means to provide an accessible approach that can apply to such diverse practice contexts and such diverse levels of focus. We might want to simplify things (a bit) without obliterating their complexity. In short, ethical literacy is a practice and like literacy in general, it looks more like reading than it looks like a book.

Despite all of this, we have a simple need to start somewhere, and we need to do this while recognizing and honouring the fact that we work in complex environments, that numerous perspectives, differences and values are in play, and that a non-complacent critical perspective is needed. By “critical,” we mean, minimally, “approaching with a questioning attitude,” so as not to automatically accept the assumptions, methods and limits that frame a given issue and partially determine the range of possibilities. “Critical” can also extend to questioning power relationships, the givens of social arrangements, and considering who benefits and who is left behind as a result (for more about critical public health ethics, see e.g., Baylis, Kenny, & Sherwin, 2008; MacDonald, 2014; and Nixon, 2006).

We must find an accessible means to engage with ethics that will help us to think and discuss together, and that will help us to go as far as we can to see issues and then take them into account in our decision making. Based on the work that has been emerging in public health ethics since about 2000, the favoured approach has been through the development and use of a number of ethics frameworks, through ethical deliberation, and through practice-based learning using case studies.

An ethics framework is roughly a guide that helps to raise ethical issues that are relevant to a given situation or type of situation. It should help its users to make a decision about what to do and “aid deliberation by making relevant values explicit.” (Dawson, 2009, p. 196) It is not an algorithm in so far as the users of the framework, the tool, are the ones who have to do the work and the thinking, notably the critical thinking. A framework ought to illuminate and guide thinking, not diminish it. It is up to the users to determine if the framework is doing its job and whether there are other important considerations that it did not help to highlight. (Note: You will find links to frameworks in the resources section below.)

Ethical deliberation in a group can be valuable for helping individuals to go beyond their own preconceptions. Diversity in the makeup of a deliberative group can also help with this, as a like-minded group can reproduce its own preconceptions, assumptions and biases without being challenged. Deliberation has its risks also; to give one example, the result of the process may simply reflect the point of view of the dominant or most forceful individuals in the group. As with frameworks, deliberation is not a fail proof process.

It is very important that structure be kept in perspective. A structuring document like a framework can have a tendency to simplify and thereby shrink the world in terms of what is judged to be relevant. Critical thinking, agency, discourse, give and take will be part of this. And that includes, crucially, the group chosen to deliberate. Practising ethics ought to make the world bigger, richer, deeper, more complex, more difficult. But through that it can yield insights – even if just little ones – that can lead to better decisions. Without seeing the ethical issues arising from our decisions, actions, future actions, policies etc., one cannot take them into account. That said, it is always a balancing act between being able to function and capturing every nuance. One benefit that results from using a framework and deliberating together is that the process can be documented. This means that afterwards, one can say “here is what we considered and here is why we chose this course of action.” Whatever the decision, having a process provides some transparency, a basis for ethically justifying the decision and for improving upon next time.

Cases are descriptions of practice-relevant scenarios whose narratives present ethical issues. They may highlight tensions between values or contain dilemmas concerning issues like managing risk, balancing paternalism against favourable health-related outcomes, for example.

In public health ethics, values are often represented in the form of principles, and are typically formulated in such a way as to be normative: that is, a principle will be worded in an imperative form implying “should.” Principles and values are generally the normative currency of public health ethics, but not always explicitly.

Values may be at odds with one another in a situation, or contested between different groups. One group may favour an intervention for its health-promoting outcomes, while another may be completely opposed to the same intervention because it infringes upon their freedom, judging that it is paternalistic (i.e., that it forces them to adopt a healthy practice, without allowing them to choose otherwise, “for their own good”). They may have no disagreement about the so-called facts of the case – they may disagree in how they value the outcomes or the processes for achieving them.

As citizens and as workers in our various professional roles, we possess our respective and diverse literacies. Literacy in ethics is one among them and it calls into play a broad set of competencies. This includes the recognition that there are many factors in play, that positions and values are contested, that power is present in decision making at every level. In order to navigate among these, a critical perspective is necessary. That is, one will be called upon to question the givens and to always consider who decides, who participates, who benefits, and why things are done this way, structured this way. It means looking at and testing our practices, questioning our own blind spots in a way that reflects a rigorous commitment to a culture of learning as opposed to a culture of compliance.

Thanks for reading. And thanks to the OHPE bulletin for the opportunity to contribute this article. Please note the many links to resources below. And please send us a note if you have a question or would like to discuss how we might help you to advance public health ethics in your work.

For more information contact authors Michael Keeling and Olivier Bellefleur, NCCHPP
at [email protected] and [email protected].

The National Collaborating Centre for Healthy Public Policy (NCCHPP) has a mandate to increase the expertise of public health actors across Canada in healthy public policy through the development, sharing and use of knowledge.

This means that we work with people who want to advance healthy public policies, ultimately to improve the health of Canadians. Ethical analysis is an essential feature of policy development. It is our goal to provide resources for practitioners to help make an ethical perspective more present in everyday practice.

Resources

All of the work listed below is open access. Please contact us and we will be happy to direct you to more. Unfortunately, much of the academic work in public health ethics is locked behind paywalls. However, among the frameworks for public health ethics, almost all of those listed in our repertoire (link below) are open access.

A few key documents about public health ethics

Introduction to Public Health Ethics 1: Background http://www.ncchpp.ca/127/Publications.ccnpps?id_article=977
Marjorie MacDonald, 2014. On the site of the NCCHPP.

Introduction to Public Health Ethics 2: Philosophical and Theoretical Foundations http://www.ncchpp.ca/127/publications.ccnpps?id_article=1424
Marjorie MacDonald, 2015. On the site of the NCCHPP.

Introduction to Public Health Ethics 3: Frameworks for Public Health Ethics
http://www.ncchpp.ca/127/publications.ccnpps?id_article=1426  
Marjorie MacDonald, 2015. On the site of the NCCHPP.

What is Moral Theory?
http://www.ncchpp.ca/548/Video.ccnpps?id_article=1098
Short (4-min.) video featuring Angus Dawson, recorded in 2011, on the site of the NCCHPP.

Public Health Ethics: What is it? And Why is it Important?
http://www.ncchpp.ca/548/Video.ccnpps?id_article=1487
15-minute narrated PowerPoint by NCCHPP, 2015.

The Promise of Public Health: Ethical Reflections
http://journal.cpha.ca/index.php/cjph/article/viewFile/701/701
Kenny, Melnychuk & Asada, 2006.

Ethics and Public Health: Forging a Strong Relationship
http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.92.2.169
Callahan & Jennings, 2002.

Public Health Ethics
http://plato.stanford.edu/entries/publichealth-ethics/  
The Stanford Encyclopedia of Philosophy. Entry by Faden & Shebaya, 2010.

Public Health Ethics Part 1 of 3: Does Your Philosophical Orientation Matter?
Part 2 of 3: Distinguishing between different types of health-related ethics and
Part 3 of 3: Applying Public Health Ethics at Your Work
http://www.hclinkontario.ca/blog/entry/public-health-ethics-part-1-of-3-...
Three Blog entries by Stephanie Massot on HC Link, 2016.

Frameworks

Repertoire - Ethics Frameworks for Public Health
http://www.ncchpp.ca/708/Repertoire_of_Frameworks.ccnpps
NCCHPP, 2016.

Collection of Adapted Summaries of Public Health Ethics Frameworks and Very Short Case Studies
http://www.ncchpp.ca/127/publications.ccnpps?id_article=1525
NCCHPP, 2016.

A framework for the ethical conduct of public health initiatives. http://www.publichealthontario.ca/en/eRepository/PHO%20%20Framework%20fo...
Public Health Ontario, 2012.

Also, this shorter document discusses the Public Health Ontario framework and provides a table of its ten guiding questions. What makes public health studies ethical? Dissolving the boundary between research and practice http://bmcmedethics.biomedcentral.com/articles/10.1186/1472-6939-15-61  
Willison et al., 2014.

Some preliminary guidance on finding and using frameworks. How can I choose a public health ethics framework that is suited to my practical needs?
http://www.ncchpp.ca/128/presentations.ccnpps?id_article=1553
PowerPoint with guidance about how to interpret key features of ethics frameworks. NCCHPP, 2016.

Cases

Population and Public Health Ethics: Cases from Research, Policy and Practice.
http://www.jcb.utoronto.ca/publications/documents/Population-and-Public-...
On the site of the Joint Centre for Bioethics at the University of Toronto, 2013.

Public Health Ethics: Cases Spanning the Globe.
http://link.springer.com/book/10.1007%2F978-3-319-23847-0
Open access. Springer, 2016.

Case Studies of Ethics During a Pandemic
http://www.ncchpp.ca/127/Publications.ccnpps?id_article=320
NCCHPP, 2010.

Online course

Public Health Ethics
https://nciph.sph.unc.edu/tws/training_list/?mode=view_series&subcat_id=...
8 modules on the site of the North Carolina Institute for Public Health/University of North Carolina Gillings School of Global Public Health, 2014.

References

Baylis, F., Kenny, N., & Sherwin, S. (2008). A relational account of public health ethics. Public Health Ethics, 1(3), 196-209.

Dawson, A. (2009). Theory and practice in public health ethics: A complex relationship. In S. Peckham & A. Hann (Eds.), Public Health Ethics and Practice, pp. 191-209. Bristol: Policy Press.

MacDonald, M. (2014). Introduction to Public Health Ethics 1: Background. Montréal: National Collaborating Centre for Healthy Public Policy. Retrieved from:
http://www.ncchpp.ca/127/Publications.ccnpps?id_article=977

Mantoura, P. & Morrison, V. (2016). Policy approaches to reducing health inequalities. Montréal: National Collaborating Centre for Healthy Public Policy. Retrieved from: http://www.ncchpp.ca/141/Publications.ccnpps?id_article=1548

Mikkonen, J. & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management. Retrieved from: http://www.thecanadianfacts.org/

Nixon, S. (2006). Critical public health ethics and Canada’s role in global health. Canadian Journal of Public Health, 97(1), 32-34. Retrieved from: http://journal.cpha.ca/index.php/cjph/article/viewFile/768/768

Schröder-Bäck, P., Duncan, P., Sherlaw, W., Brall, C., & Czabanowska, K. (2014). Teaching Seven principles for public health ethics: Towards a curriculum for a short course on ethics in public health programmes. BMC Medical Ethics 2014, 15:73. Retrieved from: http://www.biomedcentral.com/content/pdf/1472-6939-15-73.pdf