01.01.2013 Ethical check-up for public-health measures
Public-health ethics. Despite their community focus, public-health institutions must never lose sight of the needs of the individual. Measures that benefit society can harm the individual. There again, behaviour that is harmful to health can cause additional economic burdens that have to be borne by society as a whole. But which principles need to be respected when we are weighing up harm against benefit, community wellbeing against that of the individual? The answer has to lie in the ethics of public health.
Public-health interventions target the wellbeing of society as a whole or of sectors of the population, but ultimately affect the individual and can clash with the right to freedom of choice. Public-health decision-making is therefore constantly seeking a balance between the wellbeing of the community and that of the individual. Any such decisions need to weigh up carefully the benefits to society and possible harm to the individual. In their book entitled "Public Health Ethik" [Ethics of public health], Daniel Strech and Georg Marckmann discuss six criteria by which the ethics of health promotion and prevention measures can be appraised. Below is an overview of the criteria:
1. Potential benefits for the target population
Ethical principles of maximising benefits and of doing good (beneficence)
Public-health measures should generate the greatest possible health benefits for society while respecting the autonomy of the individual. An ethical evaluation of a preventive intervention must therefore begin with an appraisal of the measure's potential benefits. Before any measure is launched, scientific studies must provide sufficient evidence that it will in all probability achieve an appropriately high measure of effectiveness. With regard to early identification measures, it is particularly important that they do not result in disease phases being prolonged.
2. Potential harm to participants
Ethical principles of doing no harm (non-maleficence) and of doing good (beneficence)
Public-health interventions generally entail unavoidable negative effects. For instance, false-positive test results in the early diagnosis of cancer can lead to unnecessary treatment, or awareness-raising campaigns can result in stigmatisation of the target group (e.g. overweight children). The benefits and potential harm need to be compared and scientifically documented.
3. Right to self-determination
Ethical principles of respect for autonomy and of doing good
In liberal societies, very great importance has come to be attached to the autonomy of the individual in recent years. According to this principle, health and protection against disease are essentially the responsibility of the individual. This principle of autonomy underlies two ethical criteria that can be applied to public-health institutions. On the one hand, public health interventions should strengthen the health skills of the individual so that they can adequately exercise responsibility for their own health. Health skills are the ability to make health-related decisions based on all relevant and available information. On the other hand, participation in any intervention should, wherever possible, be voluntary. Restrictions on freedom of choice are unavoidable in some situations, for instance quarantine-based measures. Essentially, the principle of proportionality applies: all less restrictive approaches should be exhausted before resorting to the law (see "Intervention ladder" below).
Ethical principle of distributive justice
Social inequality is currently on the increase in all industrialised countries. There is thus a danger that health inequality will also rise. In Switzerland too, people with a low level of education, work status or income are already dying much earlier than the rest of the population. What is more, in the course of their shorter lives they suffer more frequently from health problems. A key criterion for judging public-health measures is therefore the extent to which they reduce health inequality. Every individual must have access to the same conditions and resources necessary for health, thus enabling them to realise their full health potential. In this respect, measures tailored to groups that are disenfranchised in terms of health are particularly valuable. But here, too, potential harm such as stigmatisation has to be taken into account. The principle of justice also means that a measure has to be accessible to all those who could benefit from it. Financial, geographical, linguistic and cultural barriers should be dismantled as far as possible.
Ethical principles of maximising benefits and of justice
Given the state of public resources, any public-health measure has to be carefully examined to determine its effectiveness. The scrutiny has to include an assessment of the "incremental cost-
effectiveness ratio". This is the ratio between additional costs and additional benefits in comparison with any alternative interventions. Here, too, it is ultimately a question of proportionality and of whether specific goals cannot be achieved at less expense and with less restrictive measures and less potential for harm (see "Intervention ladder").
Ethical principles of justice and respect for autonomy
Complex ethical considerations rarely allow a single, definitive answer to be applied. Because there is no "super" ethical principle and no defined weightings, ethical differences of opinion on public health issues are difficult to resolve. The legitimacy not only of the decision-making authority, but also of the decision-making process has to be judged in such cases. The criteria governing a legitimate and fair decision-making process are transparency of the normative and empirical basis, consistency of individual decisions, rational reasons for decisions, involvement of the population groups affected, minimisation of conflicts of interest, readiness to review a decision in the light of changed circumstances, and state or voluntary regulation which ensures that these principles are actually respected. As experience shows, political discourse additionally involves criteria concerning benefits and harm to Switzerland's market economy and federalist set-up.
What should and must the state do?
It is uncontested that health is a responsibility not only of every individual, but also of the state, just like social security or education. Inequalities have to be reduced in all these areas. Equalisation can be achieved only from the bottom up, i.e. improving the position of the disenfranchised without impairing that of the better off. The extent to which this equalisation is an obligation of society and whether the state and civil society can be held to account for it beyond the limits of individual responsibility is a matter that will concern the next generation of public-health measures.
Book: Strech Daniel, Marckmann Georg (eds.). Public Health Ethik. Lit Verlag, 2010: Berlin
The intervention ladder
The intervention ladder is a model for selecting prevention or health promotion measures that are appropriate and proportionate to requirements. Only when an intervention has no effect or ceases to be effective should a measure from the next higher rung on the ladder be adopted. As a rule, the higher the rung on the ladder, the stronger the evidence has to be that the planned measure is appropriate, effective, necessary and acceptable to those who are subject to it. Virtually all statutory measures in the public health field aim to protect the population against objects or people that are harmful to health (endangerment of others). The Narcotics Act is one of the few federal laws that involve consumption bans and thus seek to stop adults of sound mind from putting their own health at risk.
Regula Ricka, Health Policy Directorate, firstname.lastname@example.org