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Teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes

Teaching seven principles for public health ethics: towards a curriculum for a short course on... Background: Teaching ethics in public health programmes is not routine everywhere – at least not in most schools of public health in the European region. Yet empirical evidence shows that schools of public health are more and more interested in the integration of ethics in their curricula, since public health professionals often have to face difficult ethical decisions. Discussion: The authors have developed and practiced an approach to how ethics can be taught even in crowded curricula, requiring five to eight hours of teaching and learning contact time. In this way, if programme curricula do not allow more time for ethics, students of public health can at least be sensitised to ethics and ethical argumentation. This approach – focusing on the application of seven mid-level principles to cases (non-maleficence, beneficence, health maximisation, efficiency, respect for autonomy, justice, proportionality) – is presented in this paper. Easy to use ‘tools’ applying ethics to public health are presented. Summary: The crowded nature of the public health curriculum, and the nature of students participating in it, required us to devise and develop a short course, and to use techniques that were likely to provide a relatively efficient introduction to the processes, content and methods involved in the field of ethics. Keywords: Public health, Ethics, Education, Curriculum, Principle based ethics Background development of our framework. We then move on to The context for teaching ethics in public health explain and elucidate the mid-level ethical principles that Our purpose in this paper is to explain and discuss a form the content cornerstone of the framework; and the framework for a university-based short course in public educational approach that it attempts to model. Crucially, health ethics. The framework has been developed and we are not setting out simply to offer a description of what employed now in several European universities and we have done but instead to analyse, discuss and ultimately schools of public health, including the Ecole des hautes attempt to justify both content and educational approach. études en santé publique (France), Maastricht University Public health professionals are frequently called upon (the Netherlands), and Bielefeld University (Germany). in their daily practice to make both explicit and implicit We begin by discussing some aspects of the context for choices that extend beyond the objective and practical teaching public health ethics that were important in our and into the contested and ethical [1]. Balancing and deliberations on why and how to engage in such teaching: coming to conclusions about the rights and duties of and which formed fundamental starting points in the individuals, communities, populations and governments with regard to protecting and maintaining health is in many ways the central, deeply complex task of public * Correspondence: [email protected] 1 health work [2]. Yet at the same time, evidence strongly Department of International Health, School for Public Health and Primary suggests that public health professionals often receive Care (caphri), Maastricht University, Postbus 616, Maastricht, MD 6200, The Netherlands little training and guidance on how to reach decisions Faculty for Human and Health Sciences, University of Bremen, 28359 informed by careful ethical thinking and become Bremen, Germany Full list of author information is available at the end of the article © 2014 Schröder-Bäck et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 2 of 10 http://www.biomedcentral.com/1472-6939/15/73 confident in a moral sense about the ‘trade-offs’ they are influence decisions and choices about action. So those frequently required to make in practice [1,3]. involved in teaching public health ethics have a further Often facing difficult decisions without adequate train- task of evaluation and discrimination: between the com- ing and preparation in an ethical sense is, therefore, a peting normative systems and judgments of moral phi- feature of the public health context that motivated us to losophers themselves. think carefully about addressing this subject through In fact, the tasks of evaluating normative beliefs within teaching and learning. We were well aware of the pres- public health on the one hand, and normative judgments sures contributing to this state of affairs. These included made by philosophers on the other, are complementary, the already crowded nature of the public health university indeed intertwined. The foundations of value-based curriculum and the difficulty of simply employing domin- decisions in public health (as with the broader field of ant conceptions of ‘medical ethics’ to a field with (at least health care and medicine more generally) lie in moral in many respects) quite different concerns and priorities philosophical conceptions of what is valuable [9]. This [4]. Moreover, knowledge about, and evaluation of, ethics leads us to the view that our framework for public health education in teaching and learning about public health ethics teaching and learning should be based on a set of (in contrast to ethics in medical education) remains com- mid-level ethical principles, and critical appraisal and paratively scarce [3,5]. evaluation of these principles. Given these contextual issues, we were faced with an What do we mean by mid-level principles and why important set of questions: on what sorts of foundations have we chosen them to form the central content of our should teaching and learning about public health ethics framework? Such principles represent normative thinking be based? How should teaching and learning in this field that might stem from more than one moral philosophical be enacted? What are the justifications for particular theory and thus can be connected back to several theories. educational approaches? How can hard-pressed practi- They are at the mid-point of a hierarchy that at its top is tioners be sensitised to the idea that ethics permeates formed of overarching theories that attempt to explain and everything they do and that ultimately their enterprise is justify particular normative positions (for example, de- a moral one? ontology and the pre-eminence of duty in moral consider- ation, or theories that focus on the importance of Discussion consequences in ethical deliberation); and at its bottom Content foundations for teaching and learning in public comprises a range of particular rules (expressed, say, health ethics: the choice of mid-level principles through devices such as codes of conduct). Teaching and learning in public health ethics involves We argue here that because the principles are mid-level, making choices about what to teach, as well as how to and hold connections both with a number of normative teach it. The brief description and discussion of context theories and with the multiple prescriptions of codes and that we have so far engaged in leads us towards beginning guidelines, they therefore garner wide acceptance [9]. The to describe and discuss our choices in relation to what we importance of individual principles such as we are advo- actually teach about. cating is also demonstrated by their being reflected in The starting point for our discussion about the content significant parts of the bioethics and public health ethics of public health teaching is our belief that those engaged literature [9-13]. Thus the selection of these principles in it (both as teachers and learners) need to discriminate finds support and reflects positive experience in practice, between and evaluate a complex range of normative judg- as one of the authors of this current paper has established ments. Those who are working in public health are rarely in previous work [14]. Equally, such principles may not doing so without having taken up normative positions on command complete acceptance and can be challenged the purpose of the enterprise and the nature of its particu- [15], making them highly useful in terms of encourage- ment for reflection and debate. lar interventions and activities. They are operating with certain beliefs about, for example, the kind of society that This combination of acceptability on the one hand and public health should be aiming to reproduce [6] or about the potential for helpful challenge on the other provides justification for our choice of such principles. Given the the sorts of ways in which individuals, communities or populations should lead their lives [7]. So an important major task of ‘squeezing ethics in’ to the crowded public outcome of teaching and learning in public health ethics is health curriculum, employing them to provide the content foundation of our course framework allowed the opportun- the capacity to make reasoned evaluations of the range of normative beliefs and values at work in the field. ity for fairly swift appreciation of their relevance in the short As a discipline, ethics is also itself (at least in part) time that we had available; while also proposing them as stimulators of more lengthy reflection, possibly undertaken normative. It is about identifying and attempting to agree the importance of particular values (or kinds of outside and beyond formal class hours. Our choice aligns values) [8]: and how and why separate values might with the deliberations of the seminal Belmont Report: Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 3 of 10 http://www.biomedcentral.com/1472-6939/15/73 ‘[R]ules often are inadequate to cover complex situa- Beneficence tions; at times they come into conflict, and they are The obligation to produce benefit, for individual patients frequently difficult to interpret or apply. Broader ethical or clients, as we have implied above, is intimately con- principles will provide a basis on which specific rules nected to non- maleficence. Its apparently self- evident may be formulated, criticised and interpreted’ [16]. importance marks it out as the other core principle within This justification of the use of mid-level principles as the the Hippocratic tradition: physicians should heal and help content foundation of our teaching, and their location in a their patients, according to the physician’s abilities and hierarchy of normative ethical theorising and judgment, judgment [19]. The distinctive difference between the leads us briefly to describing and discussing the principles principle of non-maleficence on the one hand and that of themselves. Because of their place in the hierarchy, we beneficence on the other lies in the fact that the former need to note that an important anticipated outcome of our frequently – but not always – involves the omission of teaching and learning will be that students should be able harmful action and the latter active contribution towards to link the principles to overarching theories that exist the welfare of others [9]. ‘above’ them. Our particular concern is to encourage students towards recognising, understanding and critically Health maximisation appraising the principles’ connections to consequentialist Non-maleficence and beneficence can be understood in theories (the value of an action lies in the good or bad both deontological and consequentialist terms. Yet as consequences that it produces) such as utilitarianism; and principles they do not seem to go to the core of public deontology (the worth of an action lies prior to any consid- health values. This is at least partly because of their ten- eration of its particular consequences and instead on its dency to be associated with, and used in trying to analyse, performance as a duty). individual professional-client encounters. Even when We follow Beauchamp and Childress [9] not only in following beneficence and non-maleficence in these indi- their account of mid-level principles but also as conceiv- vidual encounters, it does not necessarily mean that popu- ing of them as being prima facie: each of equal weight at lation health is maximised, as the population is not at all the outset of moral deliberation. Naturally, during the within the focus of these micro- encounters. In the field of course of such deliberation, it is both possible and likely public health, the primary end sought is the health of the that a particular principle or principles will assume more broader constituency of the public and improvements to or less importance. Thus the prima facie status of the this are the key outcome used to measure success [10]. In principles, in our view, supports the process of careful fact, the maximisation of population health, on the one ethical deliberation and reflection; answers are not ready hand, and beneficence and non-maleficence, on the other made from the outset and choices have to be formulated. hand, can come into conflict. There are seven principles that form the content One way of conceiving of the moral impulse of benefi- grounds of our teaching framework: cence in public health terms is therefore to understand the ethical imperative to produce benefit in a wider sense and to talk of the obligation to ‘social beneficence’.Hereweare Non-maleficence thinking of theideathatpublichealth professionalshave The principle of non-maleficence – do no harm – asserts an obligation to maximise health in the populations for that a health care professional should act in such a way which they are responsible. In fact, our preference is for that he or she does no harm, even if her or his patient or the ethical principle underscoring this obligation to be re- client requests this [9]. This principle is the first to be pro- ferred to as one of health maximisation. This is because we posed because of its historical antecedence; it is related to need to be more specific than simply saying public health the famous Hippocratic ‘primum nil nocere’– first of all, professionals have a duty to produce benefit (implied by do no harm’ of medical ethics, although not identical to it the idea of ‘social beneficence’). What constitutes benefit [9,17,18]. Within public health policy and practice, there (at both individual but especially at population level) is are often occasions where degrees of harm are ‘traded off’ subject to dispute and may not necessarily be understood against the possibilities of greater harms, or perhaps posi- as ‘health’. It seems perverse to claim that public health tive benefit: for example, banning smoking in public professionals are primarily interested in other kinds of places may cause harm to individual smokers but will pre- benefit over and above maximising health and opportun- vent greater harms (and arguably produce benefit) ities for health; thus a specific principle of health maxi- through acting as a general disincentive to smoking misation, we argue, needs to constitute the third of the among the wider population. Consideration of the non- mid-level principles that form the content grounds of our maleficence principle shifts – at least – the burden of short course teaching and learning. Of course, none of this proof to those exercising potentially harmful behaviour is to deny the disputability of the concept of health, and that they are justified in doing so. the possibility of profound disagreement about what Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 4 of 10 http://www.biomedcentral.com/1472-6939/15/73 exactly it is that we are attempting to maximise [20]. welfare to be side- lined. Embedding respect for autonomy There is a strong requirement to focus on maximising firmly within public health ethics teaching and learning (population) health rather than on wider concepts of provides a fundamental reminder that every person has a the “(common) good” (whatever is understood by this), high value – qua her or his autonomy – and cannot which might well be outside the scope of public health. merely be treated as a means to the end of others’ good. We will return to this point later in our discussion. Despite this, however, the tension between individual rights and broader conceptions of public benefit is a profound Efficiency one for public health as a field of practice. This tension, There will always be more health need than resources to and the relative command that such broader conceptions deal with that need. Literally all public health systems of benefit often seem to possess, leads us to assert that in (and health care systems) worldwide lack resources. cases where autonomy restriction for wider public health These two statements prompt the advocacy of a moral goals is being contemplated (e.g. legislation banning smok- duty to use scarce health resources efficiently. This duty ing in public places or limiting movement during periods of exists at least partly because efficient use will enable contagion), the burden of proof for doing so needs always public health professionals to produce more health benefit to lie with those advocating restriction. for greater numbers of people. So a moral principle of efficiency would demand, for example, the use of the Justice evidence base and the performance of cost-benefit ana- It is equally possible to conceive of the principle of justice lyses to decide what should be done and how to do it. (sometimes ‘social justice’) as having grounds in the fun- As with the problematic of agreeing on the exact nature damental value of human autonomy. Because as humans of the ‘health’ that we are supposed to be maximising in we all have (or should have) autonomy, we all have (or the previous principle, however, there is an equal difficulty should have) equal moral worth. Thus, proposals for the here. ‘Efficiency’, along with associated notions such as unequal treatment of people again require the burden of ‘cost’ and ‘benefit’ are complex matters. For example, in proof. Justice, to the contrary, demands equal opportun- considering the cost and benefit of undertaking (or not ities. This also includes a fair distribution of health out- undertaking) a particular public health intervention, are comes in societies, which is often discussed in terms of we limiting our views of these things simply to the health public health as ‘health equity’. In a very prominent con- sector or to the effect of the intervention on the wider ception of justice in the context of health, Daniels [13] social fabric and governance of public services? Moreover, considers health equity thus a matter of fairness and just- it is conceivable to imagine limited or no action in the ice. Under Daniels’ conception of justice, health inequal- public health field as constituting ‘efficiency’ in the sense ities are unfair and unjust – and thus in conflict with of negligible resource input yielding negligible returns but health equity – if the socially controllable factors that lead the cost-benefit ratio appearing reasonable in solely eco- to health are not distributed in such a way that the health nomic terms. Here we need to emphasise that the of all citizens is protected or restored as much as possible. principle of efficiency has moral applicability, which needs Given the essential importance of health in the forma- to be disentangled from other considerations of efficiency, tion and development of every aspect of our equally valu- such as economics. (Efficiency is frequently linked to able human lives – what Boorse [22] describes as ‘species notions of ‘effectiveness’. We chose not to include ‘effect- typical functioning’– we owe each other equal access to iveness’ as an explicit principle because it is somewhat im- health goods and positive determinants of health [13]. plicit in the principle of health maximisation, and the Justice is also the principle that covers normative aspects strong sense this particular principle conveys that ethical that are often discussed in the terminology of solidarity public health action should naturally entail improvement and reciprocity. Justice does so by giving an answer to the in population health). question of what we owe to each other [13]. To have a concise set of principles, we focus only on justice. Respect for autonomy The paternalistic benevolence contained in the principles Proportionality of non-maleficence and beneficence is strongly tempered Our seventh and final principle differs somewhat from by the emphasis on respect for the autonomy of the those preceding it. As a principle, proportionality is patient who the health care professional is seeking to serve certainly normative. It demands that in weighing and balan- [9,21]. The principle of respect for autonomy extends, cing individual freedom against wider social goods, consid- however, beyond the confines of individual health care; it erations will be made in a proportionate way. According to is crucially important within the public health context. Childress et al., proportionality: The frequent focus of public health on benefit for popula- ‘Is essential to show that the probable public health ben- tions holds the potential for concern with individual efits outweigh the infringed general moral considerations Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 5 of 10 http://www.biomedcentral.com/1472-6939/15/73 […]. For instance, the policy may breach autonomy or obvious focus on practice and practical examples, can help privacy and have undesirable consequences. All positive to unpack difficulty that is simply impossible through features and benefits must be balanced against the nega- purely abstract ethical reasoning or generalised philosoph- tive features and effects […]’ [10: 173, our italics]. ical examples. They also offer the possibility of genuinely However, proportionality is also a methodological inter-disciplinary dialogue between public health practi- principle. In a manner different to the principles we have tioners and moral philosophers (both likely to be involved so far discussed, it forms the basis for casuistic reasoning in ethics-related teaching and learning in this field), at in relation to problems of individual welfare versus collect- least partly because they are ‘acceptable currency’ to both ive benefit in public health. Singer et al. [11], for example, sets of people. The requirement for inter- disciplinary argue that revelations of Chinese ethnicity in the Canadian dialogue extends, moreover, beyond simply public health outbreak of SARS demonstrate the need for fundamentally practitioners and moral philosophers to a range of others careful consideration before the release of private informa- (for example, politicians and policy makers) simply by tion in cases of pandemic disease. Beyond this, the balan- virtue of what public health is and what it tries to do. cing of private goods and public interests provides a way Case studies are not simply ‘administered’. Their form into debating many of the central problems of ethics in demands, and their function yields, dynamic group dis- public health policy and practice such as resource alloca- cussions in which the participants’ specific professional tion, the location of individual responsibility and founda- and personal experience can be brought to bear on the tional rights in the sphere of health and health care. It is problem highlighted within the case concerned. this idea of debating the proportionality of interventions, An important benefit of a case study-type approach and the help it offers in advancing understanding of situa- centrally embedded in public health ethics teaching and tions, that leads us to our conception of the principle as learning is that it allows access to an enormous range of partly methodological. Even though a methodological sources and experience. There is perhaps a tendency to principle, it is normative nevertheless, and thus we include think of case studies as artefacts solely designed by those it in our concise set of principles: as with the other princi- charged with the teaching and learning process. Of course, ples so far discussed, it contains essential prima facie the development and use of case studies designed by those moral guidance for public health practitioners. teaching short courses in ethics is important. But student- generated experience as material for case studies is Process foundations for teaching and learning in public equally, if not more, valuable because it is rooted in the health ethics: case studies and problem based-learning professional lives of learners. Sources such as books (both Having outlined and discussed the seven principles that fiction and non-fiction) and films are also rich veins that form the content basis of teaching on our short course, can be tapped in the search for source material for ethics- we turn now to describing and discussing the processes related case studies [28,29]. for teaching and learning related to these content foun- dations. Our approach can be summarised as the use of Case studies as an aid to problem-based learning: the case studies to stimulate debate and discussion around schedule for a short course in public health ethics the principles that we have identified and discussed. The Having described the value of case studies for public health intention of case study-based debate is to allow reflec- ethics teaching and learning in terms of their relevance, tion and awareness that ethical difficulties in public applicability and capacity to encourage inter-disciplinary health are not ‘black and white’; we cannot expect easy dialogue, we now turn to exemplifying a schedule for a answers, or possibly any definite answers at all [9,23,24]. short course in this area. In doing so, we start to draw out the central importance of problem-based teaching and Why case studies? learning in our schema. (Please see Table 1 for a summary Case studies in this context are short narratives describing of this schedule). a real-world or at least realistic example of a professional In a first phase, our course begins with an introductory ethical dilemma. Case studies have a central role in the discussion focusing particularly on the concept of public process of teaching and learning that aims to build the health. What do we mean by this and in particular, what capacity of moral awareness and discrimination. The use do we mean by its two constituent words, ‘public’ and of case studies has been widespread and successful in vari- ‘health’? Understanding these terms has essential rele- ous areas of medical ethical education generally [25] and vance to ethics-related discussion of the field. The term bioethics more particularly [26]. They also have a history ‘public’, for example, could be understood as the subject of success in public health, in particular public health of action (the public being represented by public institu- ethical-scientific discourse [27]. tions) or as the object of action (someone acting to protect The narratives embodied in case studies help to identify or improve the public’s health or pursuing a public good) and illustrate ethical difficulties. Case studies, with their [14,30,31]. Furthermore, different conceptions and criteria Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 6 of 10 http://www.biomedcentral.com/1472-6939/15/73 Table 1 Phases of a public health ethics course Phase What How Who Time 1 What implications can different (Interactive) Lecture Facilitator-led 3-4 hours (opportunity to understandings of “health” and “public” go into greater depth with have for public health ethical normative scope and discourses? What is ethics and how can ethical foundation of it be useful for public health practice? principles) Introduction of: Ethical principles, checklist, scheme for ethical judgement formation (Table 2). 2 Exploring and critically examining Group discussion, led by facilitator Facilitator and all students possible scenarios for resolving a case together 3 Solving a case study 1) Identification of the ethical challenge Groups of students (4-6 in At least 1-2 hours and conflict, 2) phrasing it in ethical one group), facilitator goes language, 3) suggesting a solution by from group to group to developing an ethical judgement based check if there are questions. on an ethical argument (cf. Table 2). 4 Presentation of results Presentation in class by representative(s) Students; facilitator 1-2 hours (with more of groups, discussion of group results. participates in discussions lengthy discussions) of health exist. Equally, students need to be encouraged to course we have so far argued that much public health develop an awareness that how they understand ‘health’ practice is predicated on normative assumptions and be- (both generally and in the context of public health par- liefs, this is not often rendered visible. Perhaps the greatest ticularly) will have implications for how they frame ethical difference between the discipline of ethics and other po- discourses and move towards resolving moral problems. tential disciplinary contributors to the public health cur- Yet the task of defining and describing ‘health’ itself is riculum lies in the normative focus of ethics being explicit. complex and ridden with competing values [32,33]. As a Ethical argument and resulting positions are generally consequence, the concept of public health can also be driven by the belief that this is the way that things ought interpreted differently [34,35]. Encouragement is made to be in the world [37]. This is the essential meaning of towards the idea that our understanding of the term ‘public normativity in ethics. Public health practitioners – our health’ and its constituents ’public’ and ‘health’ is likely to course participants – may struggle with the move from ‘is’ be neither wholly objective nor completely neutral; our talk to ‘ought’ that is this central characteristic of normative is always (at least partly) driven by ideology [13,20,22]. ethics. They are likely to be much more familiar with Debate about the nature of health and its relation to fields and disciplines in which evidence is developed and allied concepts such as well-being, illness, disease and presented: and arguments may be made for a particular disability is important both to help frame and under- position; but normative declarations are not (or at least stand the discussions that follow; and also to prompt at not often) made in relation to these processes. To take a the earliest stage of the course dialogue between its par- brief example, a public health practitioner may, in his or ticipants. Our experience is that those undertaking the her practice or other study, have gathered evidence for the kind of course we describe may enter it believing that existence of inequalities in health. They will most likely they broadly share similar conceptions of ‘health’ and have views on what this evidence implies for the lives of ‘public health’. This may of course be true, but we have individuals and populations. But it is unlikely (other than found that going back to first principles in the way that perhaps in a personal sense), that they would have been required to develop a normative argument related to we have described is often a means to exposing differences in understanding, which warrant fruitful exploration as inequalities (e.g. health inequalities should be regarded as part of the ethics-focused debate that follows. morally unacceptable when the determinants of these inequalities are avoidable). Ethics easily assumes this latter After this introductory session, we move on to begin discussion of ethics, focusing on its capacity to inform kind of position, but reaching it may be unfamiliar for our decision-making [36]. Our concern is to present ethics as participants. This example emphasises the importance of our a systematic field of study and a major historical contribu- tor to the development and shaping of society. We also problem-based learning approach within this course. By attempt to explain and clarify the normative character of confronting our participants with a problem and asking what should be done, and, importantly, what we need to much ethical thinking, a central feature of its character that is likely to differ from other fields and disciplines with explore and understand better to be able to justify such which participants may be more familiar. Although of action, they are guided, or hopefully guide themselves, Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 7 of 10 http://www.biomedcentral.com/1472-6939/15/73 through an essential process. This is the process that Case study: Maria Morales requires them to account for, and come to conclusions Maria Morales, head of the “Infectious Disease Control” about, not simply their knowledge and understanding of unit of the Ministry of Health of the State X, is asked by the issue being considered, but also their experience (or her minister to make a suggestion if measles immunisa- potential experience) of that issue. This connection of tion should be made mandatory in their region as recently knowledge, understanding and experience is likely to 2 children died after a measles outbreak. State X has an st nd yield different positions and conclusions than one insufficient immunisation rate (1 dose 70%, 2 55%). founded simply on cognition. It is likely to allow and Maria finds out that obligatory measles immunisation is facilitate the adoption of normative positions (this is effectively implemented in regions in Hungary and the what I should do, or what I should believe), which can Czech Republic. She knows her minister is taking her then be subject to scrutiny. This is because we are advice most seriously. What should she do? [39]. ‘allowing’ the expression of values through emphasising the importance of experience (that on which, in large Principles checklist/aide memoire part, our values are founded) [38]. At the same time, students will need points of reference  Non-Maleficence and justification for the ethical positions that they are con- ✓ Will no one be harmed by the proposed structing through their consideration of problems and intervention? cases. Thus, the step of our teaching and learning is to ✓ Are especially children prevented from harm? introduce the principles (as described and discussed  Beneficence above) that provide normative guidance (and which of ✓ Is the intervention of any good to every single course have been developed through the lengthy applica- person taking part in this intervention? tion of careful thinking related to the nature and purpose ✓ Overall, for both non-maleficence and beneficence, of health care, among other areas of human endeavour). is it possible to assess whether more benefit than Developing thinking about practical experience (either harm is produced by intervening (or not intervening) one’s own, or in a vicarious sense) and striving for justifi- and, if so, on what side (benefit or harm) does the cations or actions – or omissions – forms the essence of equation finally fall? ethical deliberation. This is practiced in discussing a case  Health Maximisation together (see phase 2, Table 1). ✓ Is the proposed intervention effective and evidence- As we made clear in the introduction to this paper, based? Does it improve population health? balancing possible courses of action and coming to con- ✓ Does it have a sustainable, long-term effect on clusions about what should be done is a key feature of the public’s health? professional life in public health. These conclusions are ✓ Is there a community added value to the not simply (or even most importantly) practical ones; proposed intervention? they are ethical. Our interest in developing the course  Efficiency we are describing and discussing emerged from a belief ✓ Is the proposed intervention cost-effective? that frequently there is little or no training or preparation ✓ Awareness of scarcity of public money; saved for ethical thinking and understanding in the process of money can be used for other goods and services. the formation of public health professionals. In our course  Respect for Autonomy up to this point, we have demonstrated the need for this ✓ Does the intervention refrain from employing understanding, proposed both tools (the principles) and coercion and manipulation? Does it foster free methods (the use of case studies and the application of choice? problem-based learning in the context of the methodology ✓ Is there really ‘informed consent’ to take part in of ethics) and are now at the final stage of applying these. the intervention? In this next phase, students are divided into small ✓ Is self-responsibility not only demanded but also groups of between four and six, depending on overall possible for every person? group size. Each group receives a different case study, ✓ Are privacy and personal data respected? which illustrates an underlying ethical problem or con- ✓ If the intervention is paternalistic, is this flict. (Please see Case study: Maria Morales for one ex- justifiable? ample case study used by the authors in their teaching ✓ Does the intervention promote the exercise of and learning). They also receive a hand out that is their autonomy? ‘toolbox’ for approaching and dealing with the problem.  Justice This contains a summary of the principles that we have ✓ Is no one (including third parties) stigmatised, elucidated and a checklist/aide memoire for their appli- discriminated against or excluded as a cation. (Please see “Principles checklist/aide memoire”). consequence of the proposed intervention? Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 8 of 10 http://www.biomedcentral.com/1472-6939/15/73 ✓ Is the institution proposing the intervention Each small group discusses the case that it has been publicly justified and acting transparently? given. They can follow the detailed steps as presented in ✓ Is the proposed intervention not putting Table 2. Participants are asked to: sub-populations at risks of being excluded from social benefits and/or universal access to health  Identify as specifically as possible what they believe care? to be the ethical challenges and potential conflicts ✓ Does the intervention exacerbate social and within the case; health inequalities (inequities)? Does it fight  Frame these challenges in explicitly ethical language inequalities (inequities)? (i.e. according to the principles and other normative ✓ Does the intervention consider and support moral theory so far discussed within the course and vulnerable sub-populations (e.g. migrants)? contained in their ‘toolbox’); ✓ Does the intervention promote rather than  Suggest a ‘solution’ or otherwise a way of dealing endanger fair (and real) equality of opportunity with the case through the development of an ethical and participation in social action? argument that again uses the resources of the ✓ Does the intervention refrain from eroding a ‘toolbox’. sense of social cohesion and solidarity? Proportionality At this last stage of the small group work phase, the ✓ Is the intervention the least infringing of possible groups formulate a justification for action that both eluci- alternatives? dates the normative processes that have led them to their ✓ Are costs and utility proportional? conclusion; and present an argument as to how and why Table 2 Steps of applied ethical reasoning; own source, inspired by [40-42] Steps Selected questions and issues raised by the example case study “Maria Morales” 1. Identify and frame in own words: What is the underlying moral conflict? Can a parents’ right to not have an intervention done with their child be overridden by the state (for someone else’s good)? Furthermore: Can parents exercise their will on behalf of their children? 2. Identify and frame in ethical words: Which ethical principles are Overall, the principles respect for autonomy and health maximisation relevant, how can they be specified and might they be in conflict to seem to be affected and seem to mutually exclude each other. But one each other? also has to ask whose autonomy is at stake. Parents’ autonomy – but what about the future autonomy of children? Furthermore, the immunising doctor might be indecisive whether to advocate for autonomy, health maximisation or non-maleficence. 3. Zoom further in: Do I have all relevant information? Can I get more What are the potential side effects of measles immunisation? How severe background information to understand all particularities? are measles for children? About how many persons (to be vaccinated against their parents’ will) can be protected, which effect would such an immunisation programme have on the incidence of measles and which side-effects could actually be prevented? 4. Are alternative solutions feasible with less moral issues/costs? Can there be alternative approaches to mandatory measles immunisation? Can one raise immunisation rates by informing, advertising, setting incentives for parents? 5. Further Specification: Do the specifications change with more If there are alternative ways that are less infringing on the respect for information? autonomy but rather support the health maximisation and the protection of those who cannot be immunised (ensuring non-maleficence), then these alternatives have a higher moral value. 6. Weighing: Are all conflicting principles and their specifications still If other measures (incentive setting, education campaigns for of equal value? immunisation) can be successfully implemented elsewhere, mandatory immunisation seems less necessary. Yet, autonomy of the parents (who are safeguarding the autonomy of their children) attains even more weight. 7. What do I conclude from the specification and weighing? What would Mandatory measles immunisation would – in this very particular situation – be my solution to the problem? not be necessary in order to achieve best health and given that it would infringe autonomy of parents (and allegedly of children), it should not be applied. 8. Integrity: Can I personally accept the conclusion drawn? It seems to be a suitable solution to – at least first – try other measures, rather than being in charge of forcing parents and children to have children’s bodies ‘invaded’ against their ‘guards’ will. 9. Act and convince: I act according to my judgment and convince I try to find resources within my professional budget and start action to colleagues and others also based on ethical reasoning. promote immunisation with other means. Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 9 of 10 http://www.biomedcentral.com/1472-6939/15/73 they have rejected and would deal with alternative possible made available. Our approach in this short course normative positions. (For example, in the presented case framework has been to develop the realisation that inde- study “Maria Morales”, population benefit versus parental pendent ethical thought is possible, but that circum- autonomy). Each small group in turn presents their justifi- stances require guidance and direction. In this respect, cation and anticipation of counter-argument to the group we suggest that although the course may be considered as a whole in a plenary session. The emphasis in this ses- as being partly akin to what Dawson [43] has described sion is not simply on exposition but also on continuing as ‘outside in’ ethics – the idea that principles act from and developing the ‘dialogue of argument and understand- the outside and guide practitioners in their ethical ing’ that the small group work has begun to generate. behaviour – it also sows the seed through case study deliberation for the emergence of ‘inside out’ (also from Summary Dawson) – oriented ethical practitioners. Developing the ethical persona of the public health ‘Outside in’- oriented ethics has value, but also has practitioner limitations, especially in the regard that, without principles In this paper, we have presented and justified our short being there, or being readily applicable (which may course framework for ethics teaching and learning in frequently be the case given the complexity of public public health. Our premise was that public health practi- health practice), the practitioner is rendered more or less tioners are frequently faced with difficult situations in helpless. While our course is based, as we have described, which they have to make decisions with explicitly moral on principles, we have tried to make clear that it is not in dimensions and yet they receive little training in the area any sense about ‘outside in’ rote learning of these princi- of ethics. The crowded nature of the public health cur- ples. Our case study and problem-based learning approach riculum, and the nature of students participating in it, allows the possibility of ‘inside out’ ethics. We encourage required us to devise and develop a short course, and to through our methods the development of independent use techniques, that were likely to provide both a rela- ethical thinking on the part of those involved in public tively efficient introduction to the processes, content health. The essence of an ‘inside out’ approach lies in the and methods involved in the field of ethics; and make development of moral capacity on the part of the individ- use of the understanding and experiences of our likely ual; encouraging them, along Aristotelian lines, to engage participants. in examination and reflection on their life and experience Our aims in presenting the framework have been in order to come to a sense of what it is to live ethically modest. Primarily, they are to raise awareness of ethical and to inhabit an ‘ethical persona’. Thus moral sense and issues within the practice of public health; and to pro- ethical expertise is developed from within. We believe that vide a ‘toolbox’ to support thinking and reasoning (and given the current organisational and institutional con- possibly decision making) on the part of public health straints of the public health curriculum, our short course professionals in training. The modesty of these aims will go some way to both provide future public health stems, as we have made clear, from a keen pragmatism practitioners with a tool-box founded on our seven princi- about what can actually be achieved in this context. ples framework of public health ethics and also foster the Of course, this is not to exclude the fundamentally im- development through its focus on experiential and portant proposition that this kind of introduction can problem-based learning, and the active application of case only ever provide a ‘snapshot’ for participants of an studies, of ‘inside out’ ethics. enormous and (we believe) essentially interesting terri- Competing interests tory. In view of the fact that the endeavour of teaching The authors declare that they have no competing interests. ethics is currently a work under development in most Authors’ contributions European schools of public health, the approach described PSB, PD and WS have drafted the article. CB and KC contributed to the and discussed here can perhaps be used as a ‘minimum development of the final draft. All authors read and approved the final standard’ curriculum for teaching and learning in this area. manuscript. We argue, however, that the limitation of our highly spe- Acknowledgements cific approach to a deeply complex area is outweighed by The authors want to acknowledge the employing institutions of the authors: its forming at least the basis for independent thought, Maastricht University, King’s College London and the École des hautes which we hope will extend well beyond the time boundar- études en santé publique. In particular we want to thank the INPES Chair in Health Promotion at the École des hautes études en santé publique that ies of the short course itself. supported the initial discussions of this paper among PSB, PD and WS. The We would hope that our short course model, or some- authors would also like to thank two reviewers for their very helpful thing approaching it, could be used until it is possible comments. for programme directors to be able to designate more Author details space for ethics modules in their programmes and until Department of International Health, School for Public Health and Primary more fitting curricula, broadly encompassing ethics, are Care (caphri), Maastricht University, Postbus 616, Maastricht, MD 6200, The Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 10 of 10 http://www.biomedcentral.com/1472-6939/15/73 Netherlands. Faculty for Human and Health Sciences, University of Bremen, 26. Veatch RM, Haddad AM, English DC: Case Studies in Biomedical Ethics: 28359 Bremen, Germany. Department of Education and Professional Studies, Decision-Making, Principles, and Cases. Oxford: Oxford University Press; 2009. 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J Clin Pharmacol 2005, 45:371–377. 19. Beauchamp TL: The ‘four principles’ approach to health care ethics. In Submit your next manuscript to BioMed Central Principles of Health Care Ethics. Secondth edition. Edited by Ashcroft R, Dawson A, Draper H, McMillan J. West Sussex, England: Wiley; 2007:3–10. and take full advantage of: 20. Seedhouse D: Health: The Foundations for Achievement. 2nd edition. Chichester: Wiley; 2001. • Convenient online submission 21. Veatch R: Doctor does not know best: why in the new century physicians • Thorough peer review must stop trying to benefit patients. J Med Philos 2000, 25:701–721. 22. Boorse C: Health as theoretical concept. Philos Sci 1977, 44:542–573. • No space constraints or color figure charges 23. Veatch RM: A Theory of Medical Ethics. New York: Basic Books; 1982. • Immediate publication on acceptance 24. Czabanowska K, Menzies LA: English for European Public Health. A Specialised • Inclusion in PubMed, CAS, Scopus and Google Scholar Course for Students and Professionals. Maastricht: Maastricht University Press; • Research which is freely available for redistribution 25. Pence GE: Classic Cases in Medical Ethics. Accounts of Cases that Have Shaped Medical Ethics, with Philosophical, Legal, and Historical Background. Thirdth Submit your manuscript at edition. Boston: McGraw Hill; 2000. www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Medical Ethics Springer Journals

Teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes

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Springer Journals
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Copyright © 2014 by Schröder-Bäck et al.; licensee BioMed Central Ltd.
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Philosophy; Ethics; Philosophy of Medicine; Theory of Medicine/Bioethics
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1472-6939
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10.1186/1472-6939-15-73
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Abstract

Background: Teaching ethics in public health programmes is not routine everywhere – at least not in most schools of public health in the European region. Yet empirical evidence shows that schools of public health are more and more interested in the integration of ethics in their curricula, since public health professionals often have to face difficult ethical decisions. Discussion: The authors have developed and practiced an approach to how ethics can be taught even in crowded curricula, requiring five to eight hours of teaching and learning contact time. In this way, if programme curricula do not allow more time for ethics, students of public health can at least be sensitised to ethics and ethical argumentation. This approach – focusing on the application of seven mid-level principles to cases (non-maleficence, beneficence, health maximisation, efficiency, respect for autonomy, justice, proportionality) – is presented in this paper. Easy to use ‘tools’ applying ethics to public health are presented. Summary: The crowded nature of the public health curriculum, and the nature of students participating in it, required us to devise and develop a short course, and to use techniques that were likely to provide a relatively efficient introduction to the processes, content and methods involved in the field of ethics. Keywords: Public health, Ethics, Education, Curriculum, Principle based ethics Background development of our framework. We then move on to The context for teaching ethics in public health explain and elucidate the mid-level ethical principles that Our purpose in this paper is to explain and discuss a form the content cornerstone of the framework; and the framework for a university-based short course in public educational approach that it attempts to model. Crucially, health ethics. The framework has been developed and we are not setting out simply to offer a description of what employed now in several European universities and we have done but instead to analyse, discuss and ultimately schools of public health, including the Ecole des hautes attempt to justify both content and educational approach. études en santé publique (France), Maastricht University Public health professionals are frequently called upon (the Netherlands), and Bielefeld University (Germany). in their daily practice to make both explicit and implicit We begin by discussing some aspects of the context for choices that extend beyond the objective and practical teaching public health ethics that were important in our and into the contested and ethical [1]. Balancing and deliberations on why and how to engage in such teaching: coming to conclusions about the rights and duties of and which formed fundamental starting points in the individuals, communities, populations and governments with regard to protecting and maintaining health is in many ways the central, deeply complex task of public * Correspondence: [email protected] 1 health work [2]. Yet at the same time, evidence strongly Department of International Health, School for Public Health and Primary suggests that public health professionals often receive Care (caphri), Maastricht University, Postbus 616, Maastricht, MD 6200, The Netherlands little training and guidance on how to reach decisions Faculty for Human and Health Sciences, University of Bremen, 28359 informed by careful ethical thinking and become Bremen, Germany Full list of author information is available at the end of the article © 2014 Schröder-Bäck et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 2 of 10 http://www.biomedcentral.com/1472-6939/15/73 confident in a moral sense about the ‘trade-offs’ they are influence decisions and choices about action. So those frequently required to make in practice [1,3]. involved in teaching public health ethics have a further Often facing difficult decisions without adequate train- task of evaluation and discrimination: between the com- ing and preparation in an ethical sense is, therefore, a peting normative systems and judgments of moral phi- feature of the public health context that motivated us to losophers themselves. think carefully about addressing this subject through In fact, the tasks of evaluating normative beliefs within teaching and learning. We were well aware of the pres- public health on the one hand, and normative judgments sures contributing to this state of affairs. These included made by philosophers on the other, are complementary, the already crowded nature of the public health university indeed intertwined. The foundations of value-based curriculum and the difficulty of simply employing domin- decisions in public health (as with the broader field of ant conceptions of ‘medical ethics’ to a field with (at least health care and medicine more generally) lie in moral in many respects) quite different concerns and priorities philosophical conceptions of what is valuable [9]. This [4]. Moreover, knowledge about, and evaluation of, ethics leads us to the view that our framework for public health education in teaching and learning about public health ethics teaching and learning should be based on a set of (in contrast to ethics in medical education) remains com- mid-level ethical principles, and critical appraisal and paratively scarce [3,5]. evaluation of these principles. Given these contextual issues, we were faced with an What do we mean by mid-level principles and why important set of questions: on what sorts of foundations have we chosen them to form the central content of our should teaching and learning about public health ethics framework? Such principles represent normative thinking be based? How should teaching and learning in this field that might stem from more than one moral philosophical be enacted? What are the justifications for particular theory and thus can be connected back to several theories. educational approaches? How can hard-pressed practi- They are at the mid-point of a hierarchy that at its top is tioners be sensitised to the idea that ethics permeates formed of overarching theories that attempt to explain and everything they do and that ultimately their enterprise is justify particular normative positions (for example, de- a moral one? ontology and the pre-eminence of duty in moral consider- ation, or theories that focus on the importance of Discussion consequences in ethical deliberation); and at its bottom Content foundations for teaching and learning in public comprises a range of particular rules (expressed, say, health ethics: the choice of mid-level principles through devices such as codes of conduct). Teaching and learning in public health ethics involves We argue here that because the principles are mid-level, making choices about what to teach, as well as how to and hold connections both with a number of normative teach it. The brief description and discussion of context theories and with the multiple prescriptions of codes and that we have so far engaged in leads us towards beginning guidelines, they therefore garner wide acceptance [9]. The to describe and discuss our choices in relation to what we importance of individual principles such as we are advo- actually teach about. cating is also demonstrated by their being reflected in The starting point for our discussion about the content significant parts of the bioethics and public health ethics of public health teaching is our belief that those engaged literature [9-13]. Thus the selection of these principles in it (both as teachers and learners) need to discriminate finds support and reflects positive experience in practice, between and evaluate a complex range of normative judg- as one of the authors of this current paper has established ments. Those who are working in public health are rarely in previous work [14]. Equally, such principles may not doing so without having taken up normative positions on command complete acceptance and can be challenged the purpose of the enterprise and the nature of its particu- [15], making them highly useful in terms of encourage- ment for reflection and debate. lar interventions and activities. They are operating with certain beliefs about, for example, the kind of society that This combination of acceptability on the one hand and public health should be aiming to reproduce [6] or about the potential for helpful challenge on the other provides justification for our choice of such principles. Given the the sorts of ways in which individuals, communities or populations should lead their lives [7]. So an important major task of ‘squeezing ethics in’ to the crowded public outcome of teaching and learning in public health ethics is health curriculum, employing them to provide the content foundation of our course framework allowed the opportun- the capacity to make reasoned evaluations of the range of normative beliefs and values at work in the field. ity for fairly swift appreciation of their relevance in the short As a discipline, ethics is also itself (at least in part) time that we had available; while also proposing them as stimulators of more lengthy reflection, possibly undertaken normative. It is about identifying and attempting to agree the importance of particular values (or kinds of outside and beyond formal class hours. Our choice aligns values) [8]: and how and why separate values might with the deliberations of the seminal Belmont Report: Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 3 of 10 http://www.biomedcentral.com/1472-6939/15/73 ‘[R]ules often are inadequate to cover complex situa- Beneficence tions; at times they come into conflict, and they are The obligation to produce benefit, for individual patients frequently difficult to interpret or apply. Broader ethical or clients, as we have implied above, is intimately con- principles will provide a basis on which specific rules nected to non- maleficence. Its apparently self- evident may be formulated, criticised and interpreted’ [16]. importance marks it out as the other core principle within This justification of the use of mid-level principles as the the Hippocratic tradition: physicians should heal and help content foundation of our teaching, and their location in a their patients, according to the physician’s abilities and hierarchy of normative ethical theorising and judgment, judgment [19]. The distinctive difference between the leads us briefly to describing and discussing the principles principle of non-maleficence on the one hand and that of themselves. Because of their place in the hierarchy, we beneficence on the other lies in the fact that the former need to note that an important anticipated outcome of our frequently – but not always – involves the omission of teaching and learning will be that students should be able harmful action and the latter active contribution towards to link the principles to overarching theories that exist the welfare of others [9]. ‘above’ them. Our particular concern is to encourage students towards recognising, understanding and critically Health maximisation appraising the principles’ connections to consequentialist Non-maleficence and beneficence can be understood in theories (the value of an action lies in the good or bad both deontological and consequentialist terms. Yet as consequences that it produces) such as utilitarianism; and principles they do not seem to go to the core of public deontology (the worth of an action lies prior to any consid- health values. This is at least partly because of their ten- eration of its particular consequences and instead on its dency to be associated with, and used in trying to analyse, performance as a duty). individual professional-client encounters. Even when We follow Beauchamp and Childress [9] not only in following beneficence and non-maleficence in these indi- their account of mid-level principles but also as conceiv- vidual encounters, it does not necessarily mean that popu- ing of them as being prima facie: each of equal weight at lation health is maximised, as the population is not at all the outset of moral deliberation. Naturally, during the within the focus of these micro- encounters. In the field of course of such deliberation, it is both possible and likely public health, the primary end sought is the health of the that a particular principle or principles will assume more broader constituency of the public and improvements to or less importance. Thus the prima facie status of the this are the key outcome used to measure success [10]. In principles, in our view, supports the process of careful fact, the maximisation of population health, on the one ethical deliberation and reflection; answers are not ready hand, and beneficence and non-maleficence, on the other made from the outset and choices have to be formulated. hand, can come into conflict. There are seven principles that form the content One way of conceiving of the moral impulse of benefi- grounds of our teaching framework: cence in public health terms is therefore to understand the ethical imperative to produce benefit in a wider sense and to talk of the obligation to ‘social beneficence’.Hereweare Non-maleficence thinking of theideathatpublichealth professionalshave The principle of non-maleficence – do no harm – asserts an obligation to maximise health in the populations for that a health care professional should act in such a way which they are responsible. In fact, our preference is for that he or she does no harm, even if her or his patient or the ethical principle underscoring this obligation to be re- client requests this [9]. This principle is the first to be pro- ferred to as one of health maximisation. This is because we posed because of its historical antecedence; it is related to need to be more specific than simply saying public health the famous Hippocratic ‘primum nil nocere’– first of all, professionals have a duty to produce benefit (implied by do no harm’ of medical ethics, although not identical to it the idea of ‘social beneficence’). What constitutes benefit [9,17,18]. Within public health policy and practice, there (at both individual but especially at population level) is are often occasions where degrees of harm are ‘traded off’ subject to dispute and may not necessarily be understood against the possibilities of greater harms, or perhaps posi- as ‘health’. It seems perverse to claim that public health tive benefit: for example, banning smoking in public professionals are primarily interested in other kinds of places may cause harm to individual smokers but will pre- benefit over and above maximising health and opportun- vent greater harms (and arguably produce benefit) ities for health; thus a specific principle of health maxi- through acting as a general disincentive to smoking misation, we argue, needs to constitute the third of the among the wider population. Consideration of the non- mid-level principles that form the content grounds of our maleficence principle shifts – at least – the burden of short course teaching and learning. Of course, none of this proof to those exercising potentially harmful behaviour is to deny the disputability of the concept of health, and that they are justified in doing so. the possibility of profound disagreement about what Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 4 of 10 http://www.biomedcentral.com/1472-6939/15/73 exactly it is that we are attempting to maximise [20]. welfare to be side- lined. Embedding respect for autonomy There is a strong requirement to focus on maximising firmly within public health ethics teaching and learning (population) health rather than on wider concepts of provides a fundamental reminder that every person has a the “(common) good” (whatever is understood by this), high value – qua her or his autonomy – and cannot which might well be outside the scope of public health. merely be treated as a means to the end of others’ good. We will return to this point later in our discussion. Despite this, however, the tension between individual rights and broader conceptions of public benefit is a profound Efficiency one for public health as a field of practice. This tension, There will always be more health need than resources to and the relative command that such broader conceptions deal with that need. Literally all public health systems of benefit often seem to possess, leads us to assert that in (and health care systems) worldwide lack resources. cases where autonomy restriction for wider public health These two statements prompt the advocacy of a moral goals is being contemplated (e.g. legislation banning smok- duty to use scarce health resources efficiently. This duty ing in public places or limiting movement during periods of exists at least partly because efficient use will enable contagion), the burden of proof for doing so needs always public health professionals to produce more health benefit to lie with those advocating restriction. for greater numbers of people. So a moral principle of efficiency would demand, for example, the use of the Justice evidence base and the performance of cost-benefit ana- It is equally possible to conceive of the principle of justice lyses to decide what should be done and how to do it. (sometimes ‘social justice’) as having grounds in the fun- As with the problematic of agreeing on the exact nature damental value of human autonomy. Because as humans of the ‘health’ that we are supposed to be maximising in we all have (or should have) autonomy, we all have (or the previous principle, however, there is an equal difficulty should have) equal moral worth. Thus, proposals for the here. ‘Efficiency’, along with associated notions such as unequal treatment of people again require the burden of ‘cost’ and ‘benefit’ are complex matters. For example, in proof. Justice, to the contrary, demands equal opportun- considering the cost and benefit of undertaking (or not ities. This also includes a fair distribution of health out- undertaking) a particular public health intervention, are comes in societies, which is often discussed in terms of we limiting our views of these things simply to the health public health as ‘health equity’. In a very prominent con- sector or to the effect of the intervention on the wider ception of justice in the context of health, Daniels [13] social fabric and governance of public services? Moreover, considers health equity thus a matter of fairness and just- it is conceivable to imagine limited or no action in the ice. Under Daniels’ conception of justice, health inequal- public health field as constituting ‘efficiency’ in the sense ities are unfair and unjust – and thus in conflict with of negligible resource input yielding negligible returns but health equity – if the socially controllable factors that lead the cost-benefit ratio appearing reasonable in solely eco- to health are not distributed in such a way that the health nomic terms. Here we need to emphasise that the of all citizens is protected or restored as much as possible. principle of efficiency has moral applicability, which needs Given the essential importance of health in the forma- to be disentangled from other considerations of efficiency, tion and development of every aspect of our equally valu- such as economics. (Efficiency is frequently linked to able human lives – what Boorse [22] describes as ‘species notions of ‘effectiveness’. We chose not to include ‘effect- typical functioning’– we owe each other equal access to iveness’ as an explicit principle because it is somewhat im- health goods and positive determinants of health [13]. plicit in the principle of health maximisation, and the Justice is also the principle that covers normative aspects strong sense this particular principle conveys that ethical that are often discussed in the terminology of solidarity public health action should naturally entail improvement and reciprocity. Justice does so by giving an answer to the in population health). question of what we owe to each other [13]. To have a concise set of principles, we focus only on justice. Respect for autonomy The paternalistic benevolence contained in the principles Proportionality of non-maleficence and beneficence is strongly tempered Our seventh and final principle differs somewhat from by the emphasis on respect for the autonomy of the those preceding it. As a principle, proportionality is patient who the health care professional is seeking to serve certainly normative. It demands that in weighing and balan- [9,21]. The principle of respect for autonomy extends, cing individual freedom against wider social goods, consid- however, beyond the confines of individual health care; it erations will be made in a proportionate way. According to is crucially important within the public health context. Childress et al., proportionality: The frequent focus of public health on benefit for popula- ‘Is essential to show that the probable public health ben- tions holds the potential for concern with individual efits outweigh the infringed general moral considerations Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 5 of 10 http://www.biomedcentral.com/1472-6939/15/73 […]. For instance, the policy may breach autonomy or obvious focus on practice and practical examples, can help privacy and have undesirable consequences. All positive to unpack difficulty that is simply impossible through features and benefits must be balanced against the nega- purely abstract ethical reasoning or generalised philosoph- tive features and effects […]’ [10: 173, our italics]. ical examples. They also offer the possibility of genuinely However, proportionality is also a methodological inter-disciplinary dialogue between public health practi- principle. In a manner different to the principles we have tioners and moral philosophers (both likely to be involved so far discussed, it forms the basis for casuistic reasoning in ethics-related teaching and learning in this field), at in relation to problems of individual welfare versus collect- least partly because they are ‘acceptable currency’ to both ive benefit in public health. Singer et al. [11], for example, sets of people. The requirement for inter- disciplinary argue that revelations of Chinese ethnicity in the Canadian dialogue extends, moreover, beyond simply public health outbreak of SARS demonstrate the need for fundamentally practitioners and moral philosophers to a range of others careful consideration before the release of private informa- (for example, politicians and policy makers) simply by tion in cases of pandemic disease. Beyond this, the balan- virtue of what public health is and what it tries to do. cing of private goods and public interests provides a way Case studies are not simply ‘administered’. Their form into debating many of the central problems of ethics in demands, and their function yields, dynamic group dis- public health policy and practice such as resource alloca- cussions in which the participants’ specific professional tion, the location of individual responsibility and founda- and personal experience can be brought to bear on the tional rights in the sphere of health and health care. It is problem highlighted within the case concerned. this idea of debating the proportionality of interventions, An important benefit of a case study-type approach and the help it offers in advancing understanding of situa- centrally embedded in public health ethics teaching and tions, that leads us to our conception of the principle as learning is that it allows access to an enormous range of partly methodological. Even though a methodological sources and experience. There is perhaps a tendency to principle, it is normative nevertheless, and thus we include think of case studies as artefacts solely designed by those it in our concise set of principles: as with the other princi- charged with the teaching and learning process. Of course, ples so far discussed, it contains essential prima facie the development and use of case studies designed by those moral guidance for public health practitioners. teaching short courses in ethics is important. But student- generated experience as material for case studies is Process foundations for teaching and learning in public equally, if not more, valuable because it is rooted in the health ethics: case studies and problem based-learning professional lives of learners. Sources such as books (both Having outlined and discussed the seven principles that fiction and non-fiction) and films are also rich veins that form the content basis of teaching on our short course, can be tapped in the search for source material for ethics- we turn now to describing and discussing the processes related case studies [28,29]. for teaching and learning related to these content foun- dations. Our approach can be summarised as the use of Case studies as an aid to problem-based learning: the case studies to stimulate debate and discussion around schedule for a short course in public health ethics the principles that we have identified and discussed. The Having described the value of case studies for public health intention of case study-based debate is to allow reflec- ethics teaching and learning in terms of their relevance, tion and awareness that ethical difficulties in public applicability and capacity to encourage inter-disciplinary health are not ‘black and white’; we cannot expect easy dialogue, we now turn to exemplifying a schedule for a answers, or possibly any definite answers at all [9,23,24]. short course in this area. In doing so, we start to draw out the central importance of problem-based teaching and Why case studies? learning in our schema. (Please see Table 1 for a summary Case studies in this context are short narratives describing of this schedule). a real-world or at least realistic example of a professional In a first phase, our course begins with an introductory ethical dilemma. Case studies have a central role in the discussion focusing particularly on the concept of public process of teaching and learning that aims to build the health. What do we mean by this and in particular, what capacity of moral awareness and discrimination. The use do we mean by its two constituent words, ‘public’ and of case studies has been widespread and successful in vari- ‘health’? Understanding these terms has essential rele- ous areas of medical ethical education generally [25] and vance to ethics-related discussion of the field. The term bioethics more particularly [26]. They also have a history ‘public’, for example, could be understood as the subject of success in public health, in particular public health of action (the public being represented by public institu- ethical-scientific discourse [27]. tions) or as the object of action (someone acting to protect The narratives embodied in case studies help to identify or improve the public’s health or pursuing a public good) and illustrate ethical difficulties. Case studies, with their [14,30,31]. Furthermore, different conceptions and criteria Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 6 of 10 http://www.biomedcentral.com/1472-6939/15/73 Table 1 Phases of a public health ethics course Phase What How Who Time 1 What implications can different (Interactive) Lecture Facilitator-led 3-4 hours (opportunity to understandings of “health” and “public” go into greater depth with have for public health ethical normative scope and discourses? What is ethics and how can ethical foundation of it be useful for public health practice? principles) Introduction of: Ethical principles, checklist, scheme for ethical judgement formation (Table 2). 2 Exploring and critically examining Group discussion, led by facilitator Facilitator and all students possible scenarios for resolving a case together 3 Solving a case study 1) Identification of the ethical challenge Groups of students (4-6 in At least 1-2 hours and conflict, 2) phrasing it in ethical one group), facilitator goes language, 3) suggesting a solution by from group to group to developing an ethical judgement based check if there are questions. on an ethical argument (cf. Table 2). 4 Presentation of results Presentation in class by representative(s) Students; facilitator 1-2 hours (with more of groups, discussion of group results. participates in discussions lengthy discussions) of health exist. Equally, students need to be encouraged to course we have so far argued that much public health develop an awareness that how they understand ‘health’ practice is predicated on normative assumptions and be- (both generally and in the context of public health par- liefs, this is not often rendered visible. Perhaps the greatest ticularly) will have implications for how they frame ethical difference between the discipline of ethics and other po- discourses and move towards resolving moral problems. tential disciplinary contributors to the public health cur- Yet the task of defining and describing ‘health’ itself is riculum lies in the normative focus of ethics being explicit. complex and ridden with competing values [32,33]. As a Ethical argument and resulting positions are generally consequence, the concept of public health can also be driven by the belief that this is the way that things ought interpreted differently [34,35]. Encouragement is made to be in the world [37]. This is the essential meaning of towards the idea that our understanding of the term ‘public normativity in ethics. Public health practitioners – our health’ and its constituents ’public’ and ‘health’ is likely to course participants – may struggle with the move from ‘is’ be neither wholly objective nor completely neutral; our talk to ‘ought’ that is this central characteristic of normative is always (at least partly) driven by ideology [13,20,22]. ethics. They are likely to be much more familiar with Debate about the nature of health and its relation to fields and disciplines in which evidence is developed and allied concepts such as well-being, illness, disease and presented: and arguments may be made for a particular disability is important both to help frame and under- position; but normative declarations are not (or at least stand the discussions that follow; and also to prompt at not often) made in relation to these processes. To take a the earliest stage of the course dialogue between its par- brief example, a public health practitioner may, in his or ticipants. Our experience is that those undertaking the her practice or other study, have gathered evidence for the kind of course we describe may enter it believing that existence of inequalities in health. They will most likely they broadly share similar conceptions of ‘health’ and have views on what this evidence implies for the lives of ‘public health’. This may of course be true, but we have individuals and populations. But it is unlikely (other than found that going back to first principles in the way that perhaps in a personal sense), that they would have been required to develop a normative argument related to we have described is often a means to exposing differences in understanding, which warrant fruitful exploration as inequalities (e.g. health inequalities should be regarded as part of the ethics-focused debate that follows. morally unacceptable when the determinants of these inequalities are avoidable). Ethics easily assumes this latter After this introductory session, we move on to begin discussion of ethics, focusing on its capacity to inform kind of position, but reaching it may be unfamiliar for our decision-making [36]. Our concern is to present ethics as participants. This example emphasises the importance of our a systematic field of study and a major historical contribu- tor to the development and shaping of society. We also problem-based learning approach within this course. By attempt to explain and clarify the normative character of confronting our participants with a problem and asking what should be done, and, importantly, what we need to much ethical thinking, a central feature of its character that is likely to differ from other fields and disciplines with explore and understand better to be able to justify such which participants may be more familiar. Although of action, they are guided, or hopefully guide themselves, Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 7 of 10 http://www.biomedcentral.com/1472-6939/15/73 through an essential process. This is the process that Case study: Maria Morales requires them to account for, and come to conclusions Maria Morales, head of the “Infectious Disease Control” about, not simply their knowledge and understanding of unit of the Ministry of Health of the State X, is asked by the issue being considered, but also their experience (or her minister to make a suggestion if measles immunisa- potential experience) of that issue. This connection of tion should be made mandatory in their region as recently knowledge, understanding and experience is likely to 2 children died after a measles outbreak. State X has an st nd yield different positions and conclusions than one insufficient immunisation rate (1 dose 70%, 2 55%). founded simply on cognition. It is likely to allow and Maria finds out that obligatory measles immunisation is facilitate the adoption of normative positions (this is effectively implemented in regions in Hungary and the what I should do, or what I should believe), which can Czech Republic. She knows her minister is taking her then be subject to scrutiny. This is because we are advice most seriously. What should she do? [39]. ‘allowing’ the expression of values through emphasising the importance of experience (that on which, in large Principles checklist/aide memoire part, our values are founded) [38]. At the same time, students will need points of reference  Non-Maleficence and justification for the ethical positions that they are con- ✓ Will no one be harmed by the proposed structing through their consideration of problems and intervention? cases. Thus, the step of our teaching and learning is to ✓ Are especially children prevented from harm? introduce the principles (as described and discussed  Beneficence above) that provide normative guidance (and which of ✓ Is the intervention of any good to every single course have been developed through the lengthy applica- person taking part in this intervention? tion of careful thinking related to the nature and purpose ✓ Overall, for both non-maleficence and beneficence, of health care, among other areas of human endeavour). is it possible to assess whether more benefit than Developing thinking about practical experience (either harm is produced by intervening (or not intervening) one’s own, or in a vicarious sense) and striving for justifi- and, if so, on what side (benefit or harm) does the cations or actions – or omissions – forms the essence of equation finally fall? ethical deliberation. This is practiced in discussing a case  Health Maximisation together (see phase 2, Table 1). ✓ Is the proposed intervention effective and evidence- As we made clear in the introduction to this paper, based? Does it improve population health? balancing possible courses of action and coming to con- ✓ Does it have a sustainable, long-term effect on clusions about what should be done is a key feature of the public’s health? professional life in public health. These conclusions are ✓ Is there a community added value to the not simply (or even most importantly) practical ones; proposed intervention? they are ethical. Our interest in developing the course  Efficiency we are describing and discussing emerged from a belief ✓ Is the proposed intervention cost-effective? that frequently there is little or no training or preparation ✓ Awareness of scarcity of public money; saved for ethical thinking and understanding in the process of money can be used for other goods and services. the formation of public health professionals. In our course  Respect for Autonomy up to this point, we have demonstrated the need for this ✓ Does the intervention refrain from employing understanding, proposed both tools (the principles) and coercion and manipulation? Does it foster free methods (the use of case studies and the application of choice? problem-based learning in the context of the methodology ✓ Is there really ‘informed consent’ to take part in of ethics) and are now at the final stage of applying these. the intervention? In this next phase, students are divided into small ✓ Is self-responsibility not only demanded but also groups of between four and six, depending on overall possible for every person? group size. Each group receives a different case study, ✓ Are privacy and personal data respected? which illustrates an underlying ethical problem or con- ✓ If the intervention is paternalistic, is this flict. (Please see Case study: Maria Morales for one ex- justifiable? ample case study used by the authors in their teaching ✓ Does the intervention promote the exercise of and learning). They also receive a hand out that is their autonomy? ‘toolbox’ for approaching and dealing with the problem.  Justice This contains a summary of the principles that we have ✓ Is no one (including third parties) stigmatised, elucidated and a checklist/aide memoire for their appli- discriminated against or excluded as a cation. (Please see “Principles checklist/aide memoire”). consequence of the proposed intervention? Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 8 of 10 http://www.biomedcentral.com/1472-6939/15/73 ✓ Is the institution proposing the intervention Each small group discusses the case that it has been publicly justified and acting transparently? given. They can follow the detailed steps as presented in ✓ Is the proposed intervention not putting Table 2. Participants are asked to: sub-populations at risks of being excluded from social benefits and/or universal access to health  Identify as specifically as possible what they believe care? to be the ethical challenges and potential conflicts ✓ Does the intervention exacerbate social and within the case; health inequalities (inequities)? Does it fight  Frame these challenges in explicitly ethical language inequalities (inequities)? (i.e. according to the principles and other normative ✓ Does the intervention consider and support moral theory so far discussed within the course and vulnerable sub-populations (e.g. migrants)? contained in their ‘toolbox’); ✓ Does the intervention promote rather than  Suggest a ‘solution’ or otherwise a way of dealing endanger fair (and real) equality of opportunity with the case through the development of an ethical and participation in social action? argument that again uses the resources of the ✓ Does the intervention refrain from eroding a ‘toolbox’. sense of social cohesion and solidarity? Proportionality At this last stage of the small group work phase, the ✓ Is the intervention the least infringing of possible groups formulate a justification for action that both eluci- alternatives? dates the normative processes that have led them to their ✓ Are costs and utility proportional? conclusion; and present an argument as to how and why Table 2 Steps of applied ethical reasoning; own source, inspired by [40-42] Steps Selected questions and issues raised by the example case study “Maria Morales” 1. Identify and frame in own words: What is the underlying moral conflict? Can a parents’ right to not have an intervention done with their child be overridden by the state (for someone else’s good)? Furthermore: Can parents exercise their will on behalf of their children? 2. Identify and frame in ethical words: Which ethical principles are Overall, the principles respect for autonomy and health maximisation relevant, how can they be specified and might they be in conflict to seem to be affected and seem to mutually exclude each other. But one each other? also has to ask whose autonomy is at stake. Parents’ autonomy – but what about the future autonomy of children? Furthermore, the immunising doctor might be indecisive whether to advocate for autonomy, health maximisation or non-maleficence. 3. Zoom further in: Do I have all relevant information? Can I get more What are the potential side effects of measles immunisation? How severe background information to understand all particularities? are measles for children? About how many persons (to be vaccinated against their parents’ will) can be protected, which effect would such an immunisation programme have on the incidence of measles and which side-effects could actually be prevented? 4. Are alternative solutions feasible with less moral issues/costs? Can there be alternative approaches to mandatory measles immunisation? Can one raise immunisation rates by informing, advertising, setting incentives for parents? 5. Further Specification: Do the specifications change with more If there are alternative ways that are less infringing on the respect for information? autonomy but rather support the health maximisation and the protection of those who cannot be immunised (ensuring non-maleficence), then these alternatives have a higher moral value. 6. Weighing: Are all conflicting principles and their specifications still If other measures (incentive setting, education campaigns for of equal value? immunisation) can be successfully implemented elsewhere, mandatory immunisation seems less necessary. Yet, autonomy of the parents (who are safeguarding the autonomy of their children) attains even more weight. 7. What do I conclude from the specification and weighing? What would Mandatory measles immunisation would – in this very particular situation – be my solution to the problem? not be necessary in order to achieve best health and given that it would infringe autonomy of parents (and allegedly of children), it should not be applied. 8. Integrity: Can I personally accept the conclusion drawn? It seems to be a suitable solution to – at least first – try other measures, rather than being in charge of forcing parents and children to have children’s bodies ‘invaded’ against their ‘guards’ will. 9. Act and convince: I act according to my judgment and convince I try to find resources within my professional budget and start action to colleagues and others also based on ethical reasoning. promote immunisation with other means. Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 9 of 10 http://www.biomedcentral.com/1472-6939/15/73 they have rejected and would deal with alternative possible made available. Our approach in this short course normative positions. (For example, in the presented case framework has been to develop the realisation that inde- study “Maria Morales”, population benefit versus parental pendent ethical thought is possible, but that circum- autonomy). Each small group in turn presents their justifi- stances require guidance and direction. In this respect, cation and anticipation of counter-argument to the group we suggest that although the course may be considered as a whole in a plenary session. The emphasis in this ses- as being partly akin to what Dawson [43] has described sion is not simply on exposition but also on continuing as ‘outside in’ ethics – the idea that principles act from and developing the ‘dialogue of argument and understand- the outside and guide practitioners in their ethical ing’ that the small group work has begun to generate. behaviour – it also sows the seed through case study deliberation for the emergence of ‘inside out’ (also from Summary Dawson) – oriented ethical practitioners. Developing the ethical persona of the public health ‘Outside in’- oriented ethics has value, but also has practitioner limitations, especially in the regard that, without principles In this paper, we have presented and justified our short being there, or being readily applicable (which may course framework for ethics teaching and learning in frequently be the case given the complexity of public public health. Our premise was that public health practi- health practice), the practitioner is rendered more or less tioners are frequently faced with difficult situations in helpless. While our course is based, as we have described, which they have to make decisions with explicitly moral on principles, we have tried to make clear that it is not in dimensions and yet they receive little training in the area any sense about ‘outside in’ rote learning of these princi- of ethics. The crowded nature of the public health cur- ples. Our case study and problem-based learning approach riculum, and the nature of students participating in it, allows the possibility of ‘inside out’ ethics. We encourage required us to devise and develop a short course, and to through our methods the development of independent use techniques, that were likely to provide both a rela- ethical thinking on the part of those involved in public tively efficient introduction to the processes, content health. The essence of an ‘inside out’ approach lies in the and methods involved in the field of ethics; and make development of moral capacity on the part of the individ- use of the understanding and experiences of our likely ual; encouraging them, along Aristotelian lines, to engage participants. in examination and reflection on their life and experience Our aims in presenting the framework have been in order to come to a sense of what it is to live ethically modest. Primarily, they are to raise awareness of ethical and to inhabit an ‘ethical persona’. Thus moral sense and issues within the practice of public health; and to pro- ethical expertise is developed from within. We believe that vide a ‘toolbox’ to support thinking and reasoning (and given the current organisational and institutional con- possibly decision making) on the part of public health straints of the public health curriculum, our short course professionals in training. The modesty of these aims will go some way to both provide future public health stems, as we have made clear, from a keen pragmatism practitioners with a tool-box founded on our seven princi- about what can actually be achieved in this context. ples framework of public health ethics and also foster the Of course, this is not to exclude the fundamentally im- development through its focus on experiential and portant proposition that this kind of introduction can problem-based learning, and the active application of case only ever provide a ‘snapshot’ for participants of an studies, of ‘inside out’ ethics. enormous and (we believe) essentially interesting terri- Competing interests tory. In view of the fact that the endeavour of teaching The authors declare that they have no competing interests. ethics is currently a work under development in most Authors’ contributions European schools of public health, the approach described PSB, PD and WS have drafted the article. CB and KC contributed to the and discussed here can perhaps be used as a ‘minimum development of the final draft. All authors read and approved the final standard’ curriculum for teaching and learning in this area. manuscript. We argue, however, that the limitation of our highly spe- Acknowledgements cific approach to a deeply complex area is outweighed by The authors want to acknowledge the employing institutions of the authors: its forming at least the basis for independent thought, Maastricht University, King’s College London and the École des hautes which we hope will extend well beyond the time boundar- études en santé publique. In particular we want to thank the INPES Chair in Health Promotion at the École des hautes études en santé publique that ies of the short course itself. supported the initial discussions of this paper among PSB, PD and WS. The We would hope that our short course model, or some- authors would also like to thank two reviewers for their very helpful thing approaching it, could be used until it is possible comments. for programme directors to be able to designate more Author details space for ethics modules in their programmes and until Department of International Health, School for Public Health and Primary more fitting curricula, broadly encompassing ethics, are Care (caphri), Maastricht University, Postbus 616, Maastricht, MD 6200, The Schröder-Bäck et al. BMC Medical Ethics 2014, 15:73 Page 10 of 10 http://www.biomedcentral.com/1472-6939/15/73 Netherlands. Faculty for Human and Health Sciences, University of Bremen, 26. Veatch RM, Haddad AM, English DC: Case Studies in Biomedical Ethics: 28359 Bremen, Germany. Department of Education and Professional Studies, Decision-Making, Principles, and Cases. Oxford: Oxford University Press; 2009. 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BMC Medical EthicsSpringer Journals

Published: Oct 7, 2014

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