Presenters: Michael Keeling and Olivier Bellefleur (NCCHPP)
Date: October 1 in English; September 24, 2015 in French.
Time: 2 p.m. to 3 p.m. (EDT) .
During this webinar, we introduced participants to:
- The general nature and role of ethics frameworks in public health,
- Summary versions of two public health ethics frameworks, and
- Cases (drawn from public health and related to healthy public policy) for deliberation using those frameworks.
A big part of this webinar was focused on a more in-depth application of a framework to a case. Participants had the opportunity to both see and contribute to applying a framework to identify the ethical implications that arise, and to deliberate towards a decision about what to do.
For participants who are less familiar with public health ethics, we recommended watching this 15-minute narrated web presentation before the PowerPoint or the recording of the webinar. In it, we introduce and contextualize public health ethics.
During the webinar participants posed several excellent questions, more than we could address during the hour. We think that they may be of general interest so we have selected five and written short responses below. Two of these are translated from the original questions in French. All of questions and comments made during the webinar are accessible in the chat box in the recorded version, available through the link above. Thanks to everyone for your active engagement.
“Sometimes situations arise that demand relatively quick responses. Developing a logic model often takes too long so instead we quickly use our usual ethical decision making tool. Is this appropriate?” [Translation from Fr.]
The decision-making context and the time that is available for ethical reflection and deliberation will clearly influence the type of tools that will be chosen for use in a particular situation. During our presentation, we used a very simple logic model in an effort to make our understanding of the intervention's intended functioning more explicit. We used it to help us to think about the intervention's efficacy as well as to see what ethical issues might arise during the different steps of the intervention. The logic model is a complementary tool that we find useful, even when we develop it very rapidly and in a rudimentary way to show the basic chain of events leading to the intended effects. That said, we do not know of any ethics frameworks that require one to use such a logic model, and we certainly do not want to give anyone the impression that it is necessary to construct a logic model to analyze the ethical issues in a case. Thus, to respond more directly to your question, if your decision-making aid or tool helps you arrive at the most informed decision possible in a time-constrained situation, we would say use it and don't cut short the time you have available for thinking and deliberating by adding another tool or element to the decision-making process.
“When considering this framework, it has a strong ‘flowchart-y' aspect to it, quite similar to that of an algorithm. Can you really argue that a framework is not an algorithm?” [translation]
On different occasions during the webinar we mentioned that frameworks are not algorithms and that they must not be treated as such. That said, frameworks can certainly give one that impression when they propose a series of questions or principles to consider, often highly structured in order or as a series of steps. Some are still more directive as to how one is to resolve tensions that arise between principles or values. But – unlike an algorithm, a framework does not show you, by itself, the “right” decision to make. Frameworks are just tools that can serve as ethical guides to highlight issues, to help with thinking and debate. Our position is that what is most necessary is a critical perspective that can serve as a lens to thinking and deliberation, as well as a broad sense of why you are conducting an ethical analysis in order to drive the process; frameworks can help with these but cannot replace them.
“I found the 6th question in the framework [proposed by Kass] quite interesting. Would you agree that defining the benefits and burdens of the program would require much community input? If so how would you use this framework to balance diverging perspectives from the community?”
The 6th question of Kass' 2001 ethics framework is: “How can the benefits and burdens of a program be fairly balanced?” Within the framework, community input is explicitly called for when it comes to determining if the program presents a balance of benefits for the burdens imposed that is right for, and according to, the community affected by the program. Balancing benefits and burdens is certainly a difficult task, but it is crucial. Since the right balance may vary according to the values held by the community, the framework calls for equitable and democratic processes to answer this question. But, interestingly, the framework does not (at least not explicitly) call for community input when it comes to determining what those benefits are burdens are. The benefits are described in terms of “public health goals” and are assessed primarily in terms of the effectiveness of the program (questions 1 and 2). The burdens are mostly characterized as four types of risks (privacy/confidentiality, liberty/self-determination, justice, and individuals' health) that should be minimized (questions 3 and 4). Benefits and burdens should also be fairly distributed (question 5). If time and resources allow, the framework could be used to find out how the members of the community would answer all of those questions. There do not seem to be any theoretical reasons against doing this. It would probably help to identify unintended benefits and burdens, as well as differing or conflicting perspectives within the community. This, in turn, could help find ways to maximize the benefits and minimize the burdens, as well as to evaluate and improve the fairness of the program.
“If we evaluate a program based on its ability to advance the community's conception of well-being, does public health have a role in changing that conception (leadership role of public health)?”
This question was raised while we were presenting Baum et al.'s (2007) ethics framework which uses the community's own conception of well-being as the criterion for evaluating the program's main result instead of a more objective criterion like health. This question is asking us to consider, for example, what the role of public health practitioners would be in promoting health as a value in a community where health was not that highly valued? How do we assess their advocacy role? There is no doubt that advocating for social norms and value changes can be an highly important role, but it could also raise specific ethical issues that would be discussed in what Gostin (2001)* called ethics for public health. In this paper, he distinguished the ethics in, of, and for public health. The kind of practical ethics that we did in the webinar would fall more under the category of ethics in public health, that is, applied ethics relating to issues that arise in practice. The ethics of public health, related to professionalism and professional conduct, concerns codes of ethics specific to public health professions. Ethics for public health deals with the ethical issues raised in advocating for the values or the moral aims of public health, like healthy communities and social justice. To our knowledge, no framework has been developed specifically for advocacy in public health ethics, or the ethics for public health.
*Gostin, L. O. (2001). Public health, ethics and human rights: A tribute to the late Jonathan Mann. Journal of Law, Medicine & Ethics, 29, 121- 130.
“Do you have examples where it is required that a public health oriented ethical framework be applied to decision making?”
No, we don't. We are not aware of examples outside of ethics committees or ethics review boards in the domain of research, and we cannot think of any specifically mandated use of an ethics framework for decision-making in public health. If anyone has an example of this to share, we would sure like to hear about it. It would be interesting to hear if there are contexts similar to mandated environmental reviews or mandated health impact assessments, but relating to ethical review of a public health program, policy or legislation.
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