Abstract
Canada is in the forefront of thinking about the unique and complex issues of contemporary public health ethics. However, an inordinate focus on the urgent issues of emergency preparedness in pandemic and reliance on bioethical analysis steeped in the autonomy and individual rights tradition of health care and research do not serve adequately as the basis for an ethic of public health with its focus on populations, communities and the common good.
This paper describes some concerns regarding the focus on pandemic ethics in isolation from public health ethics; identifies inadequacies in the dominant individualistic ethics framework; and summarizes nascent work on the concepts of relational autonomy, relational social justice and relational solidarity that can inform a re-visioning of public health ethics. While there is still much work to be done to further refine these principles, they can help to reclaim and centre the common and collective good at risk in pandemic and other emergency situations. Minimally, these principles require a policy-making process that is truly transparent, fair and inclusive; is sensitive and responsive to the workings of systemic inequalities; and requires public recognition of the fact that we enter any crisis with varying degrees of inequity. Public policy response to crisis must not forseeably increase existing inequities.
Keywords: Ethics, social justice, community, solidarity
Résumé
Le Canada est à l’avant-garde de la pensée contemporaine sur les enjeux complexes et particuliers de l’éthique en santé publique. Cependant, une attention démesurée aux problèmes urgents de la préparation antipandémique et une analyse bioéthique ancrée dans les traditions d’autonomie et de droits individuels dans les soins de santé et la recherche en santé ne constituent pas des bases assez solides pour une éthique de la santé publique axée sur les populations, les communautés et le bien commun.
Nous présentons ici certains problèmes qu’il peut y avoir à étudier l’éthique des interventions en cas de pandémie en la séparant de l’éthique en santé publique; nous cernons les lacunes du cadre éthique individualiste dominant; et nous résumons les travaux naissants sur les concepts d’autonomie relationnelle, de justice sociale relationnelle et de solidarité relationnelle qui peuvent étayer une nouvelle vision d’avenir pour l’éthique en santé publique. Il y a encore beaucoup de travail à faire pour peaufiner ces principes, mais ils peuvent déjà contribuer à revaloriser et à remettre au centre de nos préoccupations le bien commun et collectif fragilisé durant les pandémies et autres situations d’urgence. À tout le moins, ces principes nécessitent un processus décisionnel vraiment transparent, équitable et inclusif, un processus sensible et réceptif aux rouages des inégalités systémiques, et qui reconnaisse publiquement qu’au début de chaque crise il existe déjà des inégalités à divers degrés. Les politiques publiques élaborées en réponse aux crises doivent se garder de creuser ces inégalités.
Motsclés: éthique, justice sociale, communauté, solidarité
Footnotes
Acknowledgements: This work is supported by an Operating Grant (PAN- 83161) to Nuala Kenny from the Canadian Institutes of Health Research and a salary award to Françoise Baylis from the Canada Research Chairs program.
Conflict of Interest: None to declare.
References
- 1.Childress JF, Faden RR, Gaare RD, Gostin LO, Kahn J, Bonnie RJ, et al. J Law Med Ethics. 2002. Public health ethics: Mapping the terrain. [DOI] [PubMed] [Google Scholar]
- 2.Kass NE. An ethics framework for public health. Am J Public Health. 2001;91(11):1776–82. doi: 10.2105/AJPH.91.11.1776. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Beauchamp DE. Community: The neglected tradition of public health. Hastings Center Report. 1985;15:28–36. doi: 10.2307/3563066. [DOI] [PubMed] [Google Scholar]
- 4.Rogers WA. Feminism and public health ethics. J Med Ethics. 2008;32:351–54. doi: 10.1136/jme.2005.013466. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Jennings B. Public health and civic republicanism: Toward an alternative framework for public health ethics. In: Dawson A, Verweij M, editors. Ethics, Prevention and Public Health. New York, NY: Oxford University Press; 2007. [Google Scholar]
- 6.Baylis F, Kenny NP, Sherwin S. A relational account of public health ethics. Public Health Ethics. 2008;1(3):196–209. doi: 10.1093/phe/phn025. [DOI] [Google Scholar]
- 7.Singer PA, Benatar SR, Bernstein M, Abdallah SD, Dickens BM, MacRae SK, et al. Ethics and SARS: Lessons from Toronto. BMJ. 2003;327:1342–44. doi: 10.1136/bmj.327.7427.1342. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.University of Toronto, Joint Centre for Bioethics Pandemic Influenza Working Group. Stand on Guard for Thee: Ethical Considerations in Preparedness Planning for Pandemic Influenza. November 2005. Available at: https://doi.org/www.jointcentreforbioethics.ca/publications/documents/stand_on_ guard.pdf (Accessed February 19, 2009).
- 9.Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 4th ed. New York: Oxford University Press; 2004. [Google Scholar]
- 10.Public Health Agency of Canada. The Canadian Pandemic Influenza Plan for the Health Sector. Section Two: Background. 2006. [Google Scholar]
- 11.Callahan D. Individual good and common good: A communitarian approach to bioethics. Perspect Biol Med. 2003;46:496–507. doi: 10.1353/pbm.2003.0083. [DOI] [PubMed] [Google Scholar]
- 12.Powers M, Faden R. Social Justice: The Moral Foundations of Public Health and Health Policy. New York: Oxford University Press; 2006. [DOI] [PubMed] [Google Scholar]
- 13.Roberts MJ, Reich MR. Ethical analysis in public health. Lancet. 2002;359:1055–59. doi: 10.1016/S0140-6736(02)08097-2. [DOI] [PubMed] [Google Scholar]
- 14.Upshur RE. Principles for the justification of public health intervention. Can J Public Health. 2002;93(2):101–3. doi: 10.1007/BF03404547. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Sherwin S. A relational approach to autonomy in health care. In: The Canadian Feminist Health Research Network; Sherwin S, editor. The Politics of Women’s Health: Exploring Agency and Autonomy. Philadelphia, PA: Temple University Press; 1998. [Google Scholar]
- 16.Young IM. Justice and the Politics of Difference. Princeton, NJ: Princeton University Press; 1990. [Google Scholar]
- 17.Tauber AI. Medicine, public health and the ethics of rationing. Perspect Biol Med. 2002;45:16–30. doi: 10.1353/pbm.2002.0018. [DOI] [PubMed] [Google Scholar]
- 18.Houtepen R, ter Muelen R. The expectation(s) of solidarity and identity in the reconstruction of the health care system. Health Care Analysis. 2006;8:355–76. doi: 10.1023/A:1026587031528. [DOI] [PubMed] [Google Scholar]
- 19.Labonté R, Schrecker T. Globalization and Health. 2007. Globalization and social determinants of health: Promoting health equity in global governance (Part 3 of 3) p. 3. [DOI] [PMC free article] [PubMed] [Google Scholar]