An Overview of Ethics, Public Health Policy, and Politics
Abstract and Keywords
An understanding of what influences policy decisions, what determines investments for specific public health interventions, and how agreements are made regarding new programs in public health is crucial for helping navigate the ethical implications of public health programs and interventions. This chapter provides an overview of the Public Health Policy and Politics section of The Oxford Handbook of Public Health Ethics. The section’s overall goal is to highlight ethical issues emerging from the work in, and study of, politics and policy development in public health, both within countries and globally. The chapters in this section analyze a set of ethical issues related to politics and public health policies, interventions, and programs, and emphasize the importance of communication among various disciplines, such as bioethics, political science, and development studies.
The World Health Organization (WHO) is the lead agency for public health within the United Nations system, but in spite of that, or maybe because of it, the organization has come under intense scrutiny in the past decade. Concerns around the nature and type of investments in the WHO, as well as questions about the role of international health organizations and the determinants of priorities at the WHO, have been raised (Lopez, 2008; Stuckler et al., 2008). An understanding and analysis of such concerns require that the public health community prioritize critical assessments of what influences policy decisions, what determines investments for specific interventions, and how agreements are made regarding new programs in public health. International public health programs that are the focus of WHO efforts have implications for human populations, international collaborations, vulnerable segments of society, and laws across the world, and work in this space therefore invokes ethical issues that are both similar to and different from other public health actions. While there has been some attention and analysis of the ethical issues arising in this arena, they require further elaboration and reflection from those in the fields of public health, political science, bioethics, and development.
The overall goal of the Public Health Policy and Politics section of The Oxford Handbook of Public Health Ethics is to highlight ethical issues emerging from the work and study of politics and policy development in public health—nationally and globally. This section identifies a range of ethical dilemmas that arise in the politics of national and global public health policymaking, and also analyzes potential pathways for addressing them. It does not discuss ethical issues pertaining to the general fields of (p. 816) politics, political science, or development studies per se, and it does not focus on equity issues in the distribution of global resources for public health.
Infusing Ethics in Public Health Practice
By convening the authentic stakeholders involved in proposed public health efforts, informing them about shared risks, and facilitating deliberation, public health professionals can facilitate community participation in working toward acceptable public health approaches that take account of community context. In so doing, such practices will better infuse ethics into the work of public health. All too often, the initiatives and funded operations of public health fail to engage communities, preferring instead to directly provide health commodities (such as vaccines, micronutrients, bed nets, and HIV drugs) to people. The interventionist agenda crowds out an empowerment agenda, and that can perpetuate dependency, thus prompting questions about ethics. This is an important consideration for understanding the distinction between casting the mission of public health as direct service, as opposed to public health working to address unjust local institutions by creating informed and organized communities.
Power structures impact health. Those in power can be motivated by self-preservation, and power structures can therefore perpetuate the well-being of the powerful few at the expense of the health and well-being of the many who may be weak. However, a public health ethics focus can help in revealing the powerful to be myopic and short-sighted, using the analysis of “shared risks” to illuminate health threats that affect all in the population. Public health ethics offers tools and an approach to analyzing how the struggle for control of and redistribution of collective resources relates to and affects the social, natural, and built environments that impact the health of rich and poor alike.
Historically, there have always been methods in public health that use community engagement and epidemiological science to change the narrative from a political economy pitting profits against health to a communitarian realization of shared risks and shared investment in shared living spaces. Public health ethics plays a key role in the normative analysis of such tensions inherent in public health. The political economy of climate change exemplifies this perfectly. Every day, more of the rich and powerful realize that they and their children will live on a hot planet, too. This realization provides an opportunity for an understanding of shared spaces. Public health ethics can, for example, offer deliberative processes that seek to understand value systems underlying attitudes toward climate change, empirical approaches that inform decisions around climate policy, and normative ethics inquiries that demonstrate consequences of decisions taken today for the next decades.
However, public health as an action-oriented discipline must have an action-oriented ethics that moves beyond writing normative documents to more directly guiding action. (p. 817) Action-oriented public health, informed by ethics, helps to guide practice that includes deliberative spaces for stakeholders where dialogue can take place, and can lead to consensus and action agreed upon by affected parties. Infusing ethics into public health practice informs and encourages efforts to convene members of affected communities and to share information and evidence about the harms and benefits of proposed public health actions. This type of ethics activism is well outside the typical professional efforts of most academic ethicists, but convening, informing, and facilitating deliberative action by those affected is standard for public health practitioners. Public health informed by ethics is critical, then, not in the sense that it dictates actions that align with principles, but because it encourages deliberations that are more likely to result in ethically informed consensus. Ensuring authentic engagement and voice for affected community members is as important as providing relevant data for their review and shared decision-making.
The practice of community convening, informing, and engagement in policy creation is, unfortunately, not reaching many communities. Thus, too many communities are not involved in the decisions being taken for their health and welfare. Sometimes public health practitioners usurp the speaking role of the community and use their own voice as experts to dictate what should be done about shared health risks, and sometimes nobody is speaking or advocating for the community. In the short run, external voices (outside the community) may be necessary to conduct advocacy; in the long run, public health professionals need to build deliberative forums into the social structure of every community to achieve appropriate consideration of ethics in public health practice. These are the types of issues at the intersection of policy, public health, and ethics highlighted in the chapters of this section.
The four chapters in the Public Health Policy and Politics section of The Oxford Handbook of Public Health Ethics explore an important yet limited set of ethical issues in the analysis of politics and public health. Public health includes science-based services that emerged during the nineteenth and early twentieth centuries in response to serious health problems in countries experiencing rapid development. Gerald Bloom and Hayley MacGregor argue in “Global Development, Global Public Health, and Ethics” that the creation of scientific knowledge and the application of technological expertise to all aspects of economic and social organization provided a scientific and normative basis for changes in the role of the state. This led to an acceptance that governments have responsibilities for protecting populations against avoidable deaths and the high cost of ill health, and the ethical underpinning of this understanding reflected the social and political context in these nation-states. The construction of an ethical case for government interventions to protect public health, in turn, influenced understandings of the role of the state. Yet society does not yet have global agreement on ethical principles for (p. 818) complex global challenges. These principles will need to be clarified as countries build mutual agreements to address specific health issues. One cannot assume that the perspectives developed by the economically dominant countries of the last century are “universal” in this regard. An ethics of public health and development for the twenty-first century will need to emerge from a broad dialogue and process of consensus building.
In “Responsible Resource Allocation, Public Health Stewardship, and Ethics,” Robert Hecht, Daniel Arias, and Carleigh Krubiner define governance as the political processes by which decisions are reached and upheld, and stewardship as the technical processes that inform those decisions. They acknowledge that these two concepts encompass a range of morally relevant considerations in public health ethics, including promoting utility, value for money, equity, accountability, and norms of distributive and procedural justice. They take a closer look at these considerations and how they enable health systems to make ethical decisions. The authors explore ethical challenges to health that arise in systems lacking good stewardship and governance. For example, decisions must be made about how limited resources are used to promote and protect public health and what governance mechanisms will guide such decisions; and health policymakers and public health practitioners have to be responsible stewards. The chapter discusses why these issues are morally important, and it raises ethical considerations relevant to ensuring the appropriate use of public resources to improve public health through good governance and stewardship.
In “The Political Economy of Public Health: Challenges for Ethics,” Ted Schrecker begins to formulate a mission for public health ethics in seeking to shift the institutions that govern political economy. There are many historical examples where this happened. A leading example is the creation of public health departments dating back to the United Kingdom’s Public Health Act of 1848, which started an agenda where government agents measured and proposed ways to improve population health. The political economy of health connects health consequences with “upstream” inequalities in power and resources, and with policy choices and institutional processes that instantiate, reflect, and reinforce those choices—issues best considered within the frameworks of public health ethics. Understanding these processes and their connection with institutional structures and macro-scale policies is a prerequisite for intellectually responsible discussions of public health ethics. This is because the processes in question often involve life-and-death choices made by powerful actors about third parties who may have little or no ability to influence the relevant decisions. Since these choices often do not reflect any underlying economic necessity, but rather a judgment about the relative value attached to protecting the lives and wealth of differently situated members of a society, they are a key ethics concern.
Finally, in “Incorporating Ethics in Policy Change and Health Reform,” Gerard Anderson, Jeromie M. Ballreich, and Afsan Bhadelia examine the ethical considerations related to policy change and health reform and contrast ethical reasoning with policy processes. They define two broad ethical approaches for health policy: a teleological approach and a deontological approach. They then show how ethical concerns can motivate policy change and health reform, using examples from the United States, (p. 819) Mexico, and India. They argue that ethics plays a key role in health policy reform. Ethics influences the policymaking process and highlights specific health policy outcomes, and ethical concerns have been part of the policy process for years. Ethics has underpinned most health policy change and reform, such as the role of the state versus the individual, the responsibility of society for the poor, and balancing not doing any harm against shifting conceptions of goodness and virtue. The policy process and ethical reasoning share many of the same attributes, and policymakers have a responsibility to embrace ethical reasoning in the process to advance better health outcomes.
Attention to public health ethics in the arena of policy and politics will both lead to and require greater interaction among disciplines such as bioethics, political science, and development studies. The critical topics discussed in this section of The Oxford Handbook of Public Health Ethics have been relatively neglected in public health and together mark an important step forward in promoting active consideration of ethics issues in the politics of public health—including the difficult issues involving the relationships of social justice, power, and community participation—within national and global public health efforts.
Lopez, A. 2008. “Health and Health-Research Priorities: Has WHO Got It Right?” Lancet 372(9649): 1525–1527. doi:10.1016/S0140-6736(08)61632-3.Find this resource:
Stuckler, D., King, L., Robinson, H., and McKee, M. 2008. “WHO’s Budgetary Allocations and Burden of Disease: A Comparative Analysis.” Lancet 372(9649): 1563–1669. doi:10.1016/S0140-6736(08)61656-6.Find this resource: