Reading the magnificent ‘Zen and the art of motorcycle maintenance’ when I was 16 really did change my life and led me to the ideas of a few of the great philosophers either directly or through syntheses like Russell’s ‘History of Western Philosophy’. I therefore have an on-going interest in ethics as applied to work and life, although based only on the most lay understanding. Then my career path through clinical medicine, international medical relief work and UK public health has constantly led me to think about how ethical principles, whether medical, humanitarian or public health, impact on my work. My sense is that it is mostly through a very implicit and unexamined process. In these socially motivated professions, we can assume that we are on the side of the angels, well-intentioned, that our personal standards are high, and that we are therefore acting ethically, without giving the matter much further thought. I once took Raanan Gillon’s course on medical ethics in London, which added one important, if deflating, insight. Where there is ever a tricky decision to be made, applying an ethical framework can illuminate the questions, but never does the heavy lifting of coming up with any clear answer. The different ethical principles jostle and collide and are infuriatingly reluctant to line up and point in the same direction. All difficult decisions embody dilemmas; if they did not they would be easy decisions. One striking example of the problem of expecting easy solutions to difficult problems was during the 2009 Swine Flu pandemic when for a short while we thought that, for the first time in most of our careers, we might have to make really difficult decisions about use or withholding of life saving resources on a mass scale. A paper was commissioned by the UK government to look at the ethics of making such clinical decisions, and when it came out I looked through it carefully but in vain for anything that seemed likely to help a clinician answer the brutal question of who does and does not get the bed on ITU. It was all about the process of arriving at decisions, and the many cautions and pitfalls, but to me at the front line of the pandemic, it made it no easier to know what to do. Surely, I was wrong to expect more but it emphasized for me the difficulty of turning ethical discussions into practical tools. Fast forward to 2013 and a major change overtook the NHS in England. Directors of Public Health, and most of their functions, were moved out of the NHS into local Councils. The same reforms also created a new entity, Public Health England, which was part of the Department of Health, which took on many public health policy, health protection and health information functions. But most of the front line public health work went to Councils including children’s public health, sexual health, drug and alcohol services and a range of ‘lifestyle services’ such as smoking cessation and weight management programmes. DsPH also had a duty to continue providing public health advice to the local NHS commissioners, so while we were removed from the NHS, our links were maintained. This change has created a very complicated new ‘system’, with new openings, barriers and sets of relationships to manage. Those who want to understand this context in more detail can look at the brief Department of Health overview of the new system,1 or the more detailed House of Commons Library research briefing of the role of Local Authorities.2 In many ways this was a natural move for us, as Councils are involved in so many functions that impact on the determinants of health; more really than the NHS. These include education and children’s social services, adult social care, housing and the built environment, transport, leisure parks and the natural environment, economic development, environmental health and others. But unfortunately we also joined at a time when central budgets to Councils are being savaged following the world economic crisis of 2008 and the austerity policies that have been applied in the UK, and they are fighting for their very lives. And just in case that did not put enough pressure on fledgling public health teams and services in their new homes, there was an almost immediate cut to the public health grant, and then another…and another…and another…for 4 consecutive years. And as the public sector struggles to maintain its capacity, so the needs of the public that it serves, equally hit by austerity and the social pressures that it magnifies, increase. And, of course, with an ageing population there are major demographic pressures that will increase remorselessly year on year. So in managing services, teams and budgets through a long ebbing tide, even in a Council like mine that is, along with most others, positive about its new public health responsibilities, poses many practical questions that take on ethical shades. Here are a few: How do I balance my role as DPH fighting for public health services and staff with my role as a corporate director with responsibility for the whole council including other equally important services like adult care, homelessness and children’s safeguarding? How much should I protect existing front line services, like health visiting and sexual health clinics, compared to maintaining a core public health team that may impact on policy and use of resources of the wider council and NHS? How to balance resources to universal and targeted services, and by extension work on health improvement and health inequalities? The more funds are restricted the more the temptation to focus only on those in greatest need, but as the Rose Hypothesis suggests this may not promote the most overall health gain.3 There is also a danger that if the majority of the public see no personal benefit from public health services there will be a loss of public and therefore political will to sustain them. How much resource, in each area of work (e.g. drug and alcohol services), should be taken from treatment services for those with an established problem, compared to prevention to encourage others from following the same path? In all parts of the health and social care sector there is almost constant pressure on acute services meeting urgent needs which becomes a squeeze on budgets for preventive services. This happens even as the national and local rhetoric consistently talks about how essential it is to move to a more preventive system; and it operates to the detriment of public health budgets generally and real preventive work within those services? How to allocate across different age groups. Supporting families and children in their early years is so important for future lives and prospects, while ill-health and inequalities in older age groups puts so much immediate pressure on health and social care services. This brings up difficult ethical issues around the nature of personal responsibility in a world where so many powerful external influences act on people of all ages which can make it easier or harder to maintain good health. How much to make savings from existing NHS based public health services to add to high public health impact areas within councils like services for victims of domestic abuse or homeless people? Moving to Councils has made so many new areas of work much more accessible, but the same and indeed a shrinking resource can only be stretched so far. And similarly to the point above: how much time and effort might be diverted away from providing public health input into the local NHS, to try to make an impact working with other Council departments like leisure, planning, transport, housing and regeneration, or indeed other partners like the police, housing associations, voluntary sector groups, local businesses or schools and universities, whose work is also so important for the public’s health. And even within the NHS itself there are major new demands on public health time coming from the new Sustainability and Transformation Plans (STPs) which operate across larger geographies. And finally, opening up quite a different discussion, how, and how much to move from the rather top-down service provision based model that public health for the most part adopted in the NHS, to the potentially more interesting and sustainable but less easily defined and harder to achieve community led and based approaches, sometimes called ‘asset based community development’? This becomes a more pressing question as Councils are less and less able to ‘do for’ even if they want to, and are moving towards helping communities to do for themselves. It is surely not hard to understand that every important practical question being asked by DsPH has an underlying ethical dimension. Initially some of these questions were made easier to answer by uplifts to budgets as they moved from the NHS to local government, but these were often very modest, and more than wiped away by subsequent pressures and cuts, and so now these choices are real and stark. Every week I answer Freedom of Information requests from a lobby group looking to identify disinvestment in some essential area of service, and almost everyday I am in one or more meetings whose main real aim is to keep the Council or the local NHS from financial collapse. And so what can I hope for in the developing discussion of public health ethics. Much has been written in recent years about public health ethics and developing codes of ethics, and it would be useful if some of that could be built into the training and professional development of public health workers. But general principles and codes may provide limited help in day to day practice as illustrated by the flu pandemic example above. Maybe, to help locally, it would be more useful to develop some case studies that look in some detail at the ethical dimensions of the sort of local trade-offs and decisions that I have identified above. Or on the national level, other studies could do the same for policy questions like the setting of minimum unit pricing for alcohol or changes to the benefits system. And perhaps most expansively there could be an ethically informed policy discourse on the nature of a just society as seen through the important lens of health and wellbeing as one of our chief social aims and goods. All political parties now agree that everyone in society deserves a fair share of opportunity, prosperity and health (how could they not?), and yet we are so far from that ideal and there is so little agreement on what it would even look like in any detail, let alone how to move towards it. One obvious point is that we need to use whatever evidence there is to identify highest impact and return on investment, and of course we do that where there is good evidence. But in truth that is really only a very partial solution for two reasons. One is that cause and effect in complex human systems is extremely difficult to elucidate, and if we stick too rigidly to a ‘what works’ principle, we are in danger of turning away from system-based solutions that might eventually address big problems like obesity or domestic abuse, to bury ourselves in comfort zones of ‘evidence based projects’ that may only ever have minimal public health impact. The second reason is that however sophisticated our measurement of impact becomes there is really no technically satisfactory way of comparing services as disparate as, for example, intensive neonatal care, a women’s refuge, a befriending service for lonely older people, traffic calming measures or schemes to teach young parents how to cook. Allocation between such different services is far more complex and is based on historic priorities, public opinion, technological progress and the application of human and social values. And this last brings me to one of the most interesting, and both rewarding and sometimes frustrating parts of working in a council, which is that final decisions are made by politicians in a local political arena. When we were working in the NHS we could imagine, at least locally, that as practitioners we were in apolitical, and technocratic organizations like Health Authorities. But of course all that really meant was that the politics took place way above our heads where we had minimal chance of exerting any influence. So in my view moving into a more overtly political arena was a potentially positive step as it meant that we could at least talk to local politicians across a table and make our cases. But even if that optimism was a bit naïve, it did mean that DsPH had to develop a much sharper political understanding. And what is politics? Simple question! Well here are a few points to consider. Firstly politics is ultimately about the control and distribution of power and resources in society, (and as a corollary there will never be a politics-free space for such important and resource hungry projects as the NHS and social care however many arms-length bodies and Royal Commissions we might set up). Secondly, political views and outcomes will always influenced by individuals’ and groups’ vested interests (or at least their perceptions of where their interests lie). And thirdly, however, imperfectly, political views are also related to people’s ethical and social values and beliefs, and to their ideas of fairness and justice. And this brings me to my final point about how a DPH might make use of an ethical discourse. Politicians often hold strong opinions about the just society, and usually they will see their views as self-evident: ‘just common sense’, and this can make them extremely resistant to any change or modification. But a closer examination might show that they in fact reflect different theories of justice (which may themselves come from upbringing, personality, lived experience, education and training, etc). A traditional liberal view prioritizes individual ‘freedom’, which might lead to a libertarian idea of social justice that reacts against the ‘nanny state’ telling anyone how to behave. Since this is so often a criticism aimed against health promotion and health related legislation (and can come from all actual political parties), this would be a good one to use as an example of where re-framing the discussion from the overtly political to the ethical might bring some more constructive dialogue. We might do this by moving away from crude sound-bite language, towards a discussion of libertarianism, its legitimacy as a philosophical view, but also the need to modify it in some situations. For example, to protect children who are not yet fully formed moral agents, or to give some counter to the vast advertising power of certain industries which can pursue profit at the cost of major social and environmental harms. A traditional labour or socialist view prioritizes ‘equality’, which can lead to an egalitarian theory of justice, and a politics that favours redistribution. And if you ask people what a traditional conservative view was you may get many answers, but an interesting one I heard recently was that its ethical watchword is ‘responsibility’, both for self and towards others in the community. This does not map easily to a single theory of justice but may evolve into a sufficientarian approach in practice. But being able to frame discussions about redistributive policies and the balance of universal and targeted services, in the language of these and related concepts, might add a useful tool to our kit. Now these concepts are all debatable, each view has its pros, cons and qualifications, and all are much more complicated in practice than a few simple words can convey. And, as many of my colleagues have found out, any real political party or local group is a mix of individuals, each of whose views will draw, explicitly or implicitly, on some melange of different theories. And an administration, if of a single party, may be very typical of, or very different to its party’s stereotype, while a coalition… well that’s anyone’s guess. But understanding the links between these theories and practical politics does perhaps give us in the public health profession a way into local political discussions that makes the most of our professional authority, and indeed our passions, but in a way that may avoid the more combative and overtly political language that so rarely changes hearts or minds. There is certainly plenty of room for overtly and passionately political public health commentary in the world, and it is good that there are many willing to provide it. But DsPH who have survived the transition to working in local government are likely to be those who have found ways of being skilful ‘independent insiders’ promoting public health interests through a language that connects to politicians’ values and beliefs and can influence them, without immediately raising ideological opposition. This is all focused on just one small area of the greater ethical space, but others are better equipped to comment on those areas. I just wanted to give some idea of the everyday discussions and decisions in front line public health practice that seem to have difficult moral implications and that we have to answer in practice whether we want to or not. So welcome to my world. It is messy, stressful, struggling, imperfect and compromised. But I like to think that it is often useful…and even joyful because of the intellectual and personal challenges, and because there is no better route to personal satisfaction than working with a motivated organization and team for the improvement of people’s health and wellbeing. References 1 Department of Health . 2011 . The New Public Health System: Summary. [online] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/216715/dh_131897.pdf 2 Heath S . 2014 . Local Authorities’ Public Health Responsibilities (England). [online] House of Commons Library. http://researchbriefings.files.parliament.uk/documents/SN06844/SN06844.pdf 3 Rose G . Sick individuals and sick populations . Int J Epidemiol 2001 ; 30 ( 3 ): 427 – 32 . https://doi.org/10.1093/ije/30.3.427 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. 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Journal of Public Health – Oxford University Press
Published: May 29, 2018
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