What’s the Big Deal?The Ethics of Public-Private Partnerships

related to Food and Health

Jonathan H. MarksDirector, Bioethics Program, Penn State;Non-Residential Fellow, Edmond J. Safra

Center for Ethics, Harvard

Ohio State University Lecture October 16, 2013

Acknowledgments

– Edmond J. Safra Center for Ethics, Harvard– Rock Ethics Institute, Penn State

Thanks to:– Don Thompson– Chris Mayes– Susannah Rose

The Advocate

• "[b]y partnering with USDA, corporations win, USDA wins, and the American consumer wins. That's a win-win-win situation!"

– US Secretary of Agriculture Tom Vilsack

U.S. Department of Agriculture, “National Strategic Partner List,“ (2013) http://www.choosemyplate.gov/partneringprogram/national-partners/partner-list.html

The Cynic

“Next time you hear of a big food or beverage company sponsoring an after-school physical activity program in your community, you can be sure they’ll say it’s to show ‘our company’s concern for our kids’ health.’ But the real intent is to look angelic while making consumers feel good about the brand and drawing attention away from the unhealthful nature of the company’s products. ‘Posing for holy cards,’ as one of my colleagues used to put it.”

—Michael Mudd, former Executive Vice President of Global Corporate Affairs for Kraft Foods

“How to Force Ethics on the Food Industry,” New York Times, March 16, 2013, http://www.nytimes.com/2013/03/17/opinion/sunday/how-to-force-ethics-on-the-foodindustry.html?pagewanted=all&_r=2&

The Concerned

• subordination of institutional values, • mission reorientation, • weakened capacity to promote regulations

and monitor compliance,• displaced organizational priorities, and self-

censorship.Buse & Waxman, WHO Bulletin, (2001)

Research-Related Concerns

• quality of research, • research outcomes,• dissemination of research; • public trust

– in science and– in research institutions.

Walt, Brugha, and Haines, BMJ (2002)

Public Private Partnerships

“cover a wide variety of ventures involving a diversity of arrangements, varying with regard to participants, legal status, governance, management, policy-setting prerogatives, contributions and operational roles”

World Health Organization, “Public-Private Partnerships for Health,” http://www.who.int/trade/glossary/story077/en

Taxonomies of Partnership

(1) direct funding, (2) contributions in kind (goods and/or services),(3) dialogue (including information exchange),(4) joint delivery.

United Nations Standing Committee on Nutrition, “SCN Private Sector Engagement Policy, Rule 20” March, 2006, revised June 19, 2006, available at “SCN Interaction with Private Sector,” www.unsystem.org/scn/Publications/html/private_sector.htm

Taxonomy of Engagement

(1) philanthropic—described as ”peripheral” BUT…;(2) transactional—”mutual benefit”;(3) integrative—“mission mesh.”

Phases: (1) (2) (3)

James E. Austin, “Strategic Collaboration Between Nonprofits and Business,” Nonprofit and Voluntary Sector Quarterly 29.suppl.1 (2000): 69-97

Vivica I. Kraak, Paige B. Harrigan, Mark Lawrence, et al., “Balancing the Benefits and Risks of Public-Private Partnerships to Address the Global Double Burden of Malnutrition,” Public Health Nutrition 15.3 (2012): 503-17.

Philly / ABA / CHOP

http://www.philly.com/philly/blogs/heardinthehall/118077483.html

For example…

ICS Framework

• widespread or systemic practices

(often legal, and perceived as ethical)

• that undermine the integrity or trustworthiness of an institution

• and/or trust and confidence in that institution

What kinds of “institution”?• (1) academic research institutions

• (2) professional associations

• (3) scholarly and professional journals

• (4) patient advocacy organizations

• (5) government funding agencies and regulators

• and…(6) body of research as abstract institution.

Institutions: Attributes and Attitudes

Attributes:

Attitudes:

an important distinction

• If an institution is not trustworthy and/or lacks integrity, it would be problematic to take steps solely to restore trust and confidence

Integrity

• relationship between (a) the mission or purpose of an institution and (b) its practices

• an institution might be said to lack integrity if its practices predictably undermine the pursuit of the very goals in terms of which it justifies its existence – c.f. Allen Buchanan and Robert Keohane (2006)

Integrity and Public Health

• Health Halo Hazard (and/or)

• Logo effects (may lead to)

• Erosion of mission and integrity of public actor

Healthy Fast Food?• The Subway “health halo”

– Leads to belief that 1000 kcal Subway meal contains 21.3% less calories than same-calorie McDonald’s meal (585 v. 744 kcal)

– Calorie underestimates of familiar items such as sandwiches and burgers by as much as 35%

– Biasing effects of health claims on calorie estimation are as strong for consumers “highly involved” in nutrition

– Health claims lead consumers to choose side dishes containing more calories, enhancing chances of overeating

– When main course positioned as “healthy,” customers choose beverages, side dishes and desserts containing upto 131% more calories than when main course is not so positioned

• Chandon & Wansink, J. Consumer Res., 2007

Image: AAMC, The Scientific Basis of Influence and Reciprocity (June 2007);See also: Dana and Loewenstein, JAMA, 2003, esp. on denial of influence

Integrity (cont.)

• Integrity—harder cases:

– Institution with inherently conflicting mission(s)

– Institution in transition

Conflicting Mission of the USDA?

Strategic plan includes:

“expanding markets for agricultural products” AND“improving nutrition and health by providing … nutrition education and promotion”

“Mission Statement,” United States Department of Agriculture, http://www.usda.gov/wps/portal/usda/usdahome?navid=MISSION_STATEMENT

Trust and Confidence Issues

Public Trust

Industry & Professional Organizations:Professional Education (ADA-FNCE 2010)

ADA FNCE 2010 (cont.)

Industry and Professional Organizations

http://www.hersheys.com/moderationnation/

Industry & Professional Organizations

http://www.aafp.org/online/en/home/publications/news/news-now/inside-aafp/20091006cons-alli-coke.html

Global Health Philanthropy• “the Bill and Melinda Gates Foundation … will soon

be the largest stockholder of CocaCola and Kraft in the world”

David Stuckler et al., Global Health Philanthropy and Institutional Relationships: How Should Conflicts of Interest Be Addressed? PLoS Medicine (2011)

Systemic Effects--Research

• Framing effect• Technological bias• Research design• Interpretation• Dissemination

J.H.Marks, “Limits of Money Blinds,” Edmond J. Safra Center for Ethics, Money Blinds Conference, Paper Presentation, Nov. 2013

Systemic Effects--Policymaking

•preclusion of policy options (e.g. regulation)•marginalization of stakeholders•discounting of evidence•distorted development and implementation•trust and confidence issues

Mayes, Thompson, Marks (2013) (manuscript on file with authors)

SCN Principles (2006-7)

Eight Principles:•Relevance of partnership to SCN vision and mandate•Effectiveness and efficiency as relates to SCN’s goals•Management of CoI (including exclusion in some cases)•Independence from vested interests (for credibility)•Transparency•Diversity (no preferential treatment to private sector org.)•Safeguards to insulate policymaking from corporate influence•Promotion of and respect for human rightsAnd this Rule:•No financial or in-kind contributions from food-related PSO

Critical Assessment of 12 Principlesin Rowe et al./ILSI (Nutr. Rev. 2013)

1. Clearly defined and achievable public health goal2. Clear statement of rules, roles, responsibilities, accountability3. Objectives tied to partner needs, with clear baseline4. All members possess “appropriate levels of bargaining power”5. Minimize CoI by recruiting sufficient partners to mitigate influence and broaden private-sector perspectives6. Engage partners who agree on specific research questions

Critical Assessment of 12 Principlesin Rowe et al./ILSI (Nutr. Rev. 2013)

7. Engage partners committed to long-term goals and data sharing8. Engage academics and members of civil society9. Select objective scientific measurements capable of providing common ground10. Adopt research questions and methodologies established by partners with no vested financial interest in them11. Flexibility and Transparency12.Third party convener

NOTE: ILSI as PPP, and industry authors of paper.

Ethical Analysis

• Substantive Criteria

• Procedure

• Monitoring and Reassessment

J.H. Marks, “What’s the Big Deal? The Ethics of PPPs…,” Edmond J. Safra Center Working Paper, No. 11 (May 2013), available at www.ssrn.com

Ethical Analysis

• Problems with “risk-benefit analysis”• Problems with “model PPP” approach

Alternatives:• Shift presumption (e.g. against)• Systemic effects (antitrust analogy)• Counterbalancing (with uplift)• Speak Up and Collective Action

marks@psu.edu

Images: Donald B. Thompson

• Activia (FTC): http://ftc.gov/os/caselist/0823158/videos/exhibitF.swf

• Activia (SNL): http://www.youtube.com/watch?v=dfK3o_OclgU

Image credit: adweek.com

Nutrition marketing of unhealthy foods

• Recent study of six supermarkets in ND:

– 48% of products with “nutrition marketing” were high in saturated fat / sodium / sugar content

– 59% of products aim at kids and with “nutrition marketing” were high in sat.fat/sodium/sugar

Colby et al., J. Nutr. Ed. & Behav., 2010

Impact of Nutrition Marketing• Mixed evidence of public understanding of health

benefits claimed in relation to food:– Consumers don’t distinguish health claims approved

by FDA (after review of evidence) from other claims– Some evidence of “halo effect” (e.g. low cholesterol

means low fat, Andrews et al. 1998)– Some evidence that consumers may believe claim

reflects government endorsement• But evidence of impact on consumer behavior is

more challenging– Leathwood et al., Brit. J. Nutr. 2007

Fast Food Industry

Fast Food Industry (cont.)

Fast Food Industry (cont.)

Healthy Fast Food?• The Subway “health halo”

– Leads to belief that 1000 kcal Subway meal contains 21.3% less calories than same-calorie McDonald’s meal (585 v. 744 kcal)

– Calorie underestimates of familiar items such as sandwiches and burgers by as much as 35%

– Biasing effects of health claims on calorie estimation are as strong for consumers “highly involved” in nutrition

– Health claims lead consumers to choose side dishes containing more calories, enhancing chances of overeating

– When main course positioned as “healthy,” customers choose beverages, side dishes and desserts containing upto 131% more calories than when main course is not so positioned

• Chandon & Wansink, J. Consumer Res., 2007

Problems with Healthy Items• Consumers erroneously believe that eating

healthy foods in addition to unhealthy foods can decrease a meal’s calorie count– BUT not think healthy items have negative calories

• Effect stronger among individuals most concerned with managing their weight (the “dieter’s paradox”):– Burger = 711 kcal, but with salad = 615 kcal!

Chernev, J. Consumer. Psych. (2010)

Problems with Healthy Options• Presence of healthy food option:

– (1) vicariously fulfils health-related eating goals;– (2) drives attention to the least healthy option;– (3) provides license to indulge.

• “Ironic effect of self-control”: these effects are accentuated for individuals with (relatively) higher levels of self-control

• C.f. Polivy & Herman’s “what the hell effect”!

Wilcox et al., J. Consumer Research, 2009

Institutional Corruption

http://wiki.lessig.org/Institutional_Corruption

Institutional Corruption: A Framework

http://wiki.lessig.org/Institutional_Corruption

Institutional Corruption

http://wiki.lessig.org/Institutional_Corruption

Dependence Corruption

• a subset of institutional corruption (as well as individual corruption)

• e.g. the improper dependence of Congress on campaign contributors

- L. Lessig, Institutional Corruptions, EJS Working Paper No. 1 (2013)