Background
Methods
Results
Kass | Childress et al. | Public Health Leadership Society | Europhen | Nuffield | Tannahill | |
---|---|---|---|---|---|---|
Title
| An ethics framework for public health | Public health ethics: mapping the terrain | Principles of the ethical practice of public health. | Public policies, law and bioethics: a framework for producing public health policy across the European Union | Public health: ethical issues | Beyond evidence- to ethics: a decision-making framework for health promotion, public health and heath improvement |
Year issued
| 2001 | 2002 | 2002 | 2006 | 2007 | 2008 |
Area
| Public health | Public health in the USA | Public health in the USA | Public health in the EU | Public health | Health promotion, public health and health improvement |
Target group
| Professionals | Public health agents | Institutions with an explicit public health mission | Policymakers in the European Union | Policymakers in government, industry, other organisations and individuals | Decision-makers |
Type of policy or intervention that is addressed
| Interventions, policy proposals, research initiatives, programs | Interventions | Public health practice, including ideals and policies of institutions | Policy | Measures, policy | Policies, programs, services, activities |
Aim
| To indicate ethical implications of programs, to indicate defining values of public health | To provide a rough conceptual map of public health ethics, to help thinking through and resolving conflicts between promoting public health and other moral requirements | To guide institutions by clarifying distinctive elements of public health and the related ethical principles, to provide a standard to which public health institutions can be hold accountable | To help producing common approaches to public health policy across the European Union, especially with regard to tensions between private and public interests | To help considering ethical issues of measures and policy for health improvement | To indicate the function of evidence and ethics in founding policies, to indicate what actions should be implemented |
Analytic tool
|
Six-Step-Questionnaire
| None | None | None |
Intervention-Ladder
|
Decision-Making Triangle
|
Set of principles, values or recommendations
| Values are mentioned in the text, for instance: public health seeks to improve the well-being of communities
| 9 General moral considerations, for instance: producing benefits
| 12 Principles of the ethical practice of public health, for instance: public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes
| 11 Recommendations for more effective ways of developing and implementing policy that attracts greater public support, for instance: public health should strive to create an environment that structures and facilitates individual health, wellbeing and flourishing
| 10 principles (Stewardship model), for instance: acceptable public health goals include reducing the risks of ill health that result from other people's actions, such as drink driving and smoking in public places
| 10 possible ethical principles, for instance: do good
|
Main ethical values
| Well-being Privacy and confidentiality Liberty and self-determination Distributive justice Procedural justice These values have been extracted from the description of the considerations of questions 3, 5 and 6. | Well-being Utility Distributive justice and fairness Procedural justice and participation Liberty and autonomy Privacy and confidentiality Trustworthiness Transparency and openness These values have been extracted from the nine moral considerations that are provided in appendix 2. | Well-being Individual rights Participation Empowerment Equality Evidence based Transparency Effectiveness Consent Swiftness Cultural value pluralism Respect for environment Confidentiality and privacy Professionalism Trustworthiness These values have been extracted from the twelve principles that are provided in appendix 2. | Well-being Empowerment Individual rights Liberty and autonomy Personal responsibility and duties Communitarianism Participation Transparency Accountability Trust Confidentiality and privacy Swiftness These values have been extracted from the eleven recommendations that are provided in appendix 2. | Well-being Care of the vulnerable Empowerment Autonomy Fairness and equality Liberty and self determination Openness Privacy These values have been extracted from the ten principles that are provided in appendix 2. | Well-being Equity Respect Empowerment Sustainability Social responsibility Participation Openness Accountability These values have been extracted from the ten ethical principles that are provided in appendix 2. |
Criteria for dealing with ethical conflict
| -The greater the burden, the greater must be the expected public health benefit. -The more uneven the benefits and burdens are divided between groups, the greater must be the expected benefit. -Coercive programs should be kept to a minimum, should never be implemented when a less restrictive program would achieve comparable goals, and should be implemented only in the face of a clear public health need and good data demonstrating effectiveness. Disagreements about balancing burdens and benefits should be solved through a system of fair procedures that require a democratic process, including public hearings to consider minority views. | Within particular circumstances promoting the goals of public health (producing benefits, preventing harms and producing utility) may override other moral considerations (such as individual liberty or justice), provided that the following justificatory conditions are met: -Effectiveness -Proportionality -Necessity -Least infringement -Public justification Dealing with conflicts in a fair and trustworthy manner requires a process of public accountability. This involves soliciting input from the relevant publics during the formulation of public health policies as well as justifying to the relevant publics what is being undertaken after decisions have been made. | Not specified | Not specified | -The overall aim should be to achieve the desired health outcomes while minimising restrictions on people's freedom. -The more intrusive a program is, the more benefits its must create. -Ideally the principles should not be infringed, and when infringement is deemed necessary sound justification is required. -The classical harm principle, care of the vulnerable, autonomy and consent are of special importance, either because infringing them can have significant consequences, or because they are of particular relevance to public health interventions. | Documenting judgements can be of value both in consultation and in continuing constructive dialogue after decisions have been made. In case of disagreement, those who disagree may understand what decisions were based on and can argue for a different decision based on the same principles. |
Application to concrete policy issues
| Yes (that is to avian influenza preparedness) | Yes (that is to screening programs) | No | Yes (that is to a smacking ban, regulation regarding wearing car seat belts, legalising cannabis, water fluoridation, compulsory immunization, smoking ban in public places) | Yes (that is to infectious disease, obesity, alcohol and smoking and fluoridation of water) | No |
Kass: An ethics framework for public health [5, 22]
1. | What are the public health goals of the proposed program? |
2. | How effective is the program in achieving its stated goals? |
3. | What are the known or potential burdens* of the program? |
4. | Can burdens be minimised? Are there alternative approaches? |
5. | Is the program implemented fairly?** |
6. | How can the benefits and burdens of a program be fairly balanced? |
Childress et al.: Public Health Ethics [8]
• producing benefits |
• avoiding, preventing and removing harms |
• producing the maximal balance of benefits over harms and other costs (often called utility) |
• distributing benefits and burdens fairly (distributive justice) and ensuring public participation, including the participation of affected parties (procedural justice) |
• respecting autonomous choices and actions, including liberty of action |
• protecting privacy and confidentiality |
• keeping promises and commitments |
• disclosing information as well as speaking honestly and truthfully (often grouped under transparency) |
• building and maintaining trust |
Public Health Leadership Society [2, 9, 23]
1. | Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes. |
2. | Public health should achieve community health in a way that respects the rights of individuals in the community. |
3. | Public health policies, programs and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members. |
4. | Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that that the basic resources and conditions necessary for health are accessible to all. |
Europhen [10]
• Public health should strive to create an environment that structures and facilitates individual health, wellbeing and flourishing. |
• Public health has a strong role to play in ensuring that people feel part of a society so that they can make a contribution to society. |
• Public health institutions should respect the confidentiality of information that can bring harm to an individual or community if made public. |
• Where there are risks to health, public health institutions should act in a timely manner on the information available. |
Nuffield Council on Bioethics[11]
• Eliminate choice |
• Restrict choice |
• Guide choice through disincentives |
• Guide choice through incentives |
• Guide choices through changing the default policy |
• Enable choice |
• Provide information |
• Do nothing or simply monitor the current situation |
Tannahill: Beyond evidence - to ethics[12]
Discussion
Conclusions
Appendix 1. Search strategy in pubmed
Appendix 2. Overview of principles and values in the frameworks
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producing benefits
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avoiding, preventing and removing harms
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producing the maximal balance of benefits over harms and other costs (often called utility)
-
distributing benefits and burdens fairly (distributive justice) and ensuring public participation, including the participation of affected parties (procedural justice)
-
respecting autonomous choices and actions, including liberty of action
-
protecting privacy and confidentiality
-
keeping promises and commitments
-
disclosing information as well as speaking honestly and truthfully (often grouped under transparency) and
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building and maintaining trust
-
reducing the risks of ill health that result from other people's actions, such as drink-driving and smoking in public places;
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reducing causes of ill-health relating to environmental conditions, for instance provision of clean drinking water and setting housing standards;
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protecting and promoting the health of children and other vulnerable people;
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helping people to overcome addictions that are harmful to health or helping them to avoid unhealthy behaviours;
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ensuring that it is easy for people to lead a healthy life, for example by providing convenient and safe opportunities for exercise;
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ensuring that people have appropriate access to medical services; and
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reducing unfair health inequalities.
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not attempt to coerce adults to lead healthy lives;
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minimise the use of measures that are implemented without consulting people (either individually or using democratic procedures); and
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minimize measures that are very intrusive or conflict with important aspects of personal life, such as privacy