what is ‘public health ethics’? - gobierno | gob.mx€¦ · what is ‘public health ethics’?...
TRANSCRIPT
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Aim• Much of the literature on PHE assumes
what I will call a ‘minimal’ approach –looks to a narrow idea of bioethics – really medical ethics
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Structure1. Minimal PHE
a) Medical Ethicsb) Lawc) Liberty and Public Health
2. Substantive PHEa) Concept of Public Health and PHEb) Aims of PHEc) Complexityd) Values
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1.a. History of Medical Ethics
– Professional-Patient Relationship (and related ethical issues – e.g. Informed consent and confidentiality)
– Core issues: abortion and euthanasia etc
– High technology (e.g. reproduction etc)
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1.b. Law
• Law has tended to focus on the individual:• Protect property• Protect body from interference• Focus on contract, tort, crime• Appeal to rights
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1.c. Liberty and Public Health
• Limited range of values on display in discussion
• Focus on state as paternalistic• Idea of liberty as non-interference• This provides a model where there is a
presumption in favour of liberty unless there is ‘good reason’not to follow
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“Millian” Tradition• John Stuart Mill’s ‘On Liberty’ (1859)
• Respect individual autonomy • Our preferences are our own business. • Health promoters may have an obligation
to provide information – but anything further may be unethical
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So – is that our Conclusion?
• PHE is a set of issues to join the list of topics in medical ethics?
• We can just use traditional medical ethics to address these issues?
• No need for any theoretical innovation?
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CDC Slides• I want to argue that things are more
complex than this suggests
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Obesity Trends* Among U.S. AdultsBRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
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Obesity Trends* Among U.S. AdultsBRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
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Obesity Trends* Among U.S. AdultsBRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4”person)
No Data <10% 10%–14%
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Obesity Trends* Among U.S. AdultsBRFSS, 1988
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
![Page 14: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/14.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
![Page 15: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/15.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
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Obesity Trends* Among U.S. AdultsBRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
![Page 17: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/17.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
![Page 18: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/18.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
![Page 19: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/19.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
![Page 20: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/20.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
![Page 21: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/21.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
![Page 22: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/22.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
![Page 23: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/23.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
![Page 24: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/24.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
![Page 25: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/25.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
![Page 26: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/26.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
![Page 27: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/27.jpg)
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Obesity Trends* Among U.S. AdultsBRFSS, 2002
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
![Page 28: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/28.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 2003
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
![Page 29: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/29.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 2004
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
![Page 30: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/30.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
![Page 31: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/31.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
![Page 32: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/32.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
![Page 33: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/33.jpg)
Obesity Trends* Among U.S. AdultsBRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
![Page 34: What is ‘Public Health Ethics’? - Gobierno | gob.mx€¦ · What is ‘Public Health Ethics’? Angus Dawson University of Birmingham, UK ... 1.c. Liberty and Public Health •](https://reader035.vdocuments.us/reader035/viewer/2022070801/5f0295967e708231d404fdbd/html5/thumbnails/34.jpg)
• Let’s assume for now that: – BMI is satisfactory as a tool– Obesity is correlated with a range of poorer
health outcomes– We are talking about a democratic society
with accountable PH structures
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Minimal PHE and Obesity• What causal or explanatory story can
‘minimal’ PHE provide?• What are the options for intervention?
• Individual choice and responsibility
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2.a. Substantive PHE
• An alternative is to use the idea of public health as the foundation for public health ethics
• Begin with concept of ‘public health’– Health of a population or group– Attaining such ends often requires
collective activities
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2.b. Aims of PH
• Prevent or reduce harm• Promote health• Reduce inequities
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2.c. Complexity
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Complexity• One response is to despair and choose to
do nothing
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Link to Ecological PH• Focus on choices/actions of individual
clearly looks problematic• If we want to do anything, will need wide
range of policy actions
• Look at humans as biological, social, economic and political beings
• Need to focus on context
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2.d. Values
• Liberty is an important value – but can be weighed against others
• No presumption in its favour
• Substantive PHE tries to capture other values of importance to work in PH
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Values• Are we free to choose in the relevant
sense? (Social network theory)• Are collective responses irrelevant - unless
(all?) consent?• How important is prevention?
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Values
• Focus on the conditions for human flourishing
• Values such as solidarity, social justice, common goods etc
• PH is vital for healthy society (not just in sense of population health – but also a society where we would want to live)
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Possible Objections• Paternalism
– Danger this is just question begging
• Internal practice – Doesn’t mean cannot be critical, revisionary– Democratic, public accountability
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Conclusions• Minimal PHE provides answers but they
seems problematic• Substantive PHE:
– arises from and is sympathetic to the aims of PH
– and seeks to capture the relevant complexity and relevant values
– Links to ecological and systems approaches