The Ethical Basis of the Practice of Public Health

1-30-11

The Ethical Basis of the Practice of Public Health

ID250 Harvard School of Public Health Spring 1 2011

Instructor: Daniel Wikler, Ph.D.

Office: 641 Huntington Avenue, 2-204, Longwood, BostonOffice hour: W 9:30 – 10:20 am

Telephone: 617-432-2365 (mobile: 617-817-6617)

Assistant: Maynard Clark, , 617-432-3998

Teaching Assistants: Stephanie Morain ()

Eugene Chislenko ()

For physicians in clinical practice, the individual patient has the highest priority. This fiduciary responsibility is the basis of medical ethics, creating a bond of trust between healer and patient. The ethics of public health are rather more complicated. In public health, the professional sometimes acts on behalf of a population or a group rather than an individual. Within this group, some individuals may receive less benefit than others, or may even be placed at risk. Success in the practice of public health sometimes is contingent on the professional’s ability to persuade people to do what they prefer not to do, or even what they consider to be wrong to do---such as providing clean needles to addicts, or condoms to sexually active teenagers. The public health practitioner serves the public, but the public in most cases does not know the practitioner personally. If they do, those who are helped may be resentful rather than grateful.

What resources do public health professionals bring to these ethical dilemmas? The starting point is the individual practitioner’s good will, ethical sensitivity, and moral integrity. We hope that every student is a person of good character, capable of empathy, understanding, and tolerance; and also intelligent, self-critical, and well-informed. Moreover, those who choose public health as a profession seem, as a group, to be unusually dedicated to humanitarian ideals. Even so, those working in the field are bound to encounter moral dilemmas that seem difficult to resolve, if not insoluble.

The study of ethics in the curriculum of a school of public health can build on the important moral strengths that many people attracted to careers in this field bring with them. Through reading and, above all, through discussion, mutual criticism and debate, we can improve our ability to identify ethical dilemmas and choices where they may formerly have seemed invisible. We can get a feel for what counts as a satisfactory justification for a choice when we are faced with a dilemma, and we can improve on our ability to criticize the cloudy or evasive thinking and rationalization that we and others may offer when we have not thought a problem through adequately. And, for those who have not yet studied ethical theory, we can begin to glimpse the possibility that order might be imposed on the jumble of feelings, attitudes, and beliefs that we bring to the ethics class.

These theories, mostly by philosophers, attempt to generate answers to questions about right and wrong and about justice that are internally consistent and that are in accord with evidence. Each theory represents a particular understanding or view about what features of right actions, good outcomes, noble characters, and just societies account for their ethical standing: what makes right actions right, good outcomes good, and just distributions of resources just.

There exists no consensus on which of these theories are best, nor on any single method for resolving moral dilemmas or debates. By the end of the course, it is possible that you will remain uncertain which of the moral theories we have discussed is closest to the truth, and some of the dilemmas of public health practice that we debate in class may seem further from resolution than they seemed before the course began. This lack of closure is frustrating, but it is intellectually more honest, and indeed it is probably desirable. You have the whole of your careers to work out the answers, and if our discussions and mutual challenges can be provocative enough, you will want to continue in that quest indefinitely.

This is not a remedial course in moral philosophy, and students will not be given a comprehensive survey of historical or contemporary thinking about ethics. Nevertheless, our selective study of concepts in ethical theory and modes of argument will, if successful, enhance your own response to ethical dilemmas that you will encounter in your professional life, not by teaching a list of moral rules but by acquiring and exercising the skill of moral argument, analysis, and debate.

Methods, assignments, grading:

Two examinations will test the student’s comprehension of readings, lectures, and discussions. A term paper provides the opportunity to explore an ethical issue in public health in greater depth. Students may choose the topics, contingent on approval by the instructor, but they must be submitted to the instructor by February 24 and approved.

Assessment of student performance:

1. Mid-term examination (25%), posted Feb. 16, due Feb.19 by 11:59 p.m.
2. Final examination (25%), posted March 9, due March 12 by 11:59 p.m.

Note: Exams are take-home. Students should devote no more than twohours in taking it. You may consult your notes of class discussions, and all assigned readings.

1. Term paper (10 pages): topic due Feb. 24. Paper should be submitted as an email attachment to by 11:59 p.m. on March 7. 40%
2. Class discussion and participation: 10%

Most sessions will not be formal lectures. We will advance our understanding through discussion. Moral reflection involves argument, and all students are encouraged to participate. Ethical analysis is a kind of skill, learned only with practice. Students whose English is tentative may find it difficult to follow what is said in class and to contribute themselves. If you find that this is a problem for you, please consult the instructors.
We may have the option of videotaping the class if participants think that they would make use the tapes.

Some classes will focus on theories, and others on the facts involved in cases. The instructors have opinions
on most of these, but the students will not always be able to tell what these opinions are. What matters is whether our views are clearly thought out and expressed, that we remain open to constructive criticism,
and that we take advantage of the debate to refine our thinking.

Lectures and Reading

Can ethics be taught? This question has been debated for millennia. To some extent, people differ in their answers because they are talking about different things:

• Character: An “internal compass” that inclines you toward reliability, honesty, fairness, benevolence, and similar moral virtues is the result of favorable nurturing and socialization (and, perhaps, genes). These traits of character will not be acquired or lost in an ethics class.
• Theories: If we think of “learning ethics” as understanding moral theories, then ethics classes are useful; but one can also read up on these on one’s own.
• Moral Reasoning: When we confront ethical dilemmas – situations in which even people of good will and good character are puzzled about what choice to make – we must try to reason our way through. Ideally, moral reasoning is clear-headed, informed, impartial (where appropriate), and free of self-deception. To some extent, these are skills that you can acquire by practice.

Our emphasis will be on moral reasoning. Though we can (fortunately) assume that students in this class have strong altruistic motivation, not everyone is used to articulating the reasons for their ethical choices, subjecting them to logical analysis and criticism, and accepting responsibility for defending them. In class, we will practice and model this aspect of ethics. The goal is not to persuade or advocate to others, but rather to understand what is at stake in moral dilemmas and, most importantly, to identify the course of action that, in light of available evidence and taking into account all relevant moral considerations, one ought to pursue. The first and most important “audience” for moral arguments for the positions we take on these issues is ourselves. They can help us to determine whether we have good reasons for our positions. Secondarily, skill in articulating good arguments for our positions can help in carrying the public health mission in explaining the rationale for policies and interventions to the public.

The role of class discussion and of the readings for ID250 is different from courses in which lectures are used primarily to help students to understand the textbook. The readings are useful (and in some cases, essential) in preparing for class discussion, in making sense of what transpires in class, and for supplementing and extending what id done in class. But the class discussion is the primary vehicle for instruction.

Only rarely will class time be used to explain assigned articles; in some cases, they won’t be mentioned at all. We will simply assume that students have (or will have) read the required readings, which are relatively few in number (though some require slow and careful reading; a few may require rereading). You will get more out of the course if you can read the supplementary works, but you may decide to read these later on.

Reading Assignments

Monday, January 24: Introduction

No reading is required before the first class. These essays provide overviews:

1. Daniel Wikler and Richard Cash, “Ethical Issues in Global Public Health.” in Robert Beaglehole, eds., Global Public Health: A New Era, 2nd edition, 2003
2. Daniel Wikler and Dan Brock, Population-Level Bioethics: Mapping a New Agenda.” In Angus Dawson and Marcel Verweij, Eds, Ethics, Prevention, and Public Health, 2007.
3. Marc J Roberts and Michael Reich, “Ethical analysis in public health.” The Lancet 2002; 359: 1055-59

Clickthrough “Science Direct”

Wednesday, January 26: Morality and moral deliberation

1. Bernard Williams, “The Amoralist”, “Subjectivism”, and “Relativism”, from his
   Morality: An Introduction to Ethics, pp. 1-39, Harper, 1972

Monday, January 31: Consequentialist Theories of Morality

1. Will Kymlicka, “Utilitarianism” in his Contemporary Political Philosophy: An Introduction 10-53.
2. Derek Parfit, “What Makes Someone’ Life Go Best?”, in his Reasons and Persons, pp. 493-502, Oxford University Press, 1986.
3. Daniel Kahneman and Jason Riis, “Living, and Thinking About It: Two Perspectives on Life.”
   In F.A. Huppert, N. Baylis & B. Keverne (Eds.), The Science of Well-being, 2005.

Wednesday, February 2: Non-Consequentialist Theories of Morality

1 Frances Kamm, “Nonconsequentialism.” Chapter 1 of her
Intricate Ethics: Rights, Responsibilities, and Permissible Harm, 2007.

Further reading:

1. Alex Voorhoeve, “In search of the deep structure of morality. An interview with Frances Kamm,”
   in Alex Voorhoeve, Conversations on Ethics, Oxford University Press, 2009

Monday, February 7: Life Paths – excerpts from films by David MacDougall

-No reading for this class; please make a start on Feb. 9 reading.

Wednesday , February 9: Theories of Justice

1. Will Kymlicka, “Liberal Equality” in his Contemporary Political Philosophy: An Introduction, 53-102

Further reading:

1. Ronald Dworkin, “What is Equality? Part 2, Equality of Resources” Philosophy & Public Affairs
   10(4), 283-345, 1981 (Autumn)

Monday, Febrary 14 Justice and Health I (guest lecturer: Stephanie Morain)

1. Norman Daniels, Chapters 2 and 3 of Just Health, Cambridge U. Press, 2007
2. Tim Wilkinson, Review of Just Health, Public Health Ethics 1(3) 268-272, 2008

Further reading:

1. Sarah Marchand, “Health and Liberal Egalitarian Theories of Justice”, 01/24/2006 paper
   (posted on the course website; by permission of the author)
2. Jonathan Wolff, “Health”, from his Ethics and Public Policy (forthcoming 2011). Posted on the course website.

Wednesday, February 16, Justice and Health II

1. Amartya Sen, Why Health Equity?Health Economics 11:659-666, 2002 (December)
   (plus a comment, ibid., 65-66, by Alan Williams)
2. Sarah Marchand and Daniel Wikler, and Bruce Landesman, “Class, Health, and Justice”.
   Milbank Quarterly 76(3), 1998, 449-467.
3. Daniel Hausman, What's Wrong with Health Inequalities?Journal of Political Philosophy 15(1) 2007, pp. 44-66

Further reading:

1. Daniel Hausman, “Benevolence, Justice, Well-Being and the Health Gradient” Public Health Ethics 2(3):235-243, 2009
2. Norman Daniels, Bruce Kennedy, and Ichiro Kawachi, Justice is good for our health. Boston Review February-March 2000

[Mid-term exam will be posted tonight; due by Feb. 19, before 11:59 p.m.]

[Term paper topics must be approved by February 24]

Wednesday, February 23: Priority-Setting

1. Daniel Wikler, Dan Brock, Sarah Marchand, and Tessa Tan-Torres, Quantitative Methods for Priority-Setting in Health: Ethical Issues. In Richard Ashcroft and Angus Dawson, eds., Principles of Healthcare Ethics, 2nd edition, Oxford U. Press
2. Daniel Hausman, “Valuing Health.”Philosophy & Public Affairs 43(3), 2006
3. Jeff Richardson and John McKie, Empiricism, ethics and orthodox economic theory: what is the appropriate basis for decision-making in the health sector? Social Science and Medicine 60(2), 265-275 (2005).
   

Further reading:

1. Dan Brock and Daniel Wikler, Ethical Issues in Resource Allocation, Research, and New Product Development. In Dean Jamison et al. Disease Control Priorities in Developing Countries. Oxford University Press (259-265 only – part of Chapter 14)
2. Dolan, P., & Kahneman, D. (2008). Interpretations of utility and their implications for the valuation of health. The Economic Journal 118(1), 2008.
   Erik Nord et al, Who cares about cost? Does economic analysis impose or reflect social values?
   Health Policy34 (1995) 79-94.
3. Lydia Kapiriri, Trude Arnesen and Ole Frithjof Norheim, Is cost-effectiveness analysis preferred to severity of disease as the main guiding principle in priority setting in resource poor settings?
   The case of Uganda. Cost Effectiveness and Resource Allocation 2004, 2:1
   

Monday, February 28: Healthy Populations, Healthy Individuals

1. Geoffrey Rose, Sick individuals and sick populations. International Journal of Epidemiology
   14(1) 32-38, 1985 (reprinted, with an introduction by Michael Marmot, in the Bulletin of the World Health Organization 79(10), 2001
2. A group of reassessments of Rose’s thesis, published in The Lancet in 2001
3. Robert Proctor, “Nazi Medicine and Public Health Policy” Dimensions 10 (2) 1996.
4. Daniel Wikler, Can we learn from eugenics?Journal of Medical Ethics 25, 1999, 183-194
5. Martin Pernick,Eugenics and Public Health in American History. American Journal of Public Health 87(11), November 1997, 1767-1772

Anthony Rodgers, Majid Ezzati et al, Distribution of Major Health Risks: Findings from the Global Burden of Disease Study. PLoS Medicine 1(1): e27, 2004

Wednesday March 2: Disasters, State Power and Public Health

1. World Health Organization, Ethical considerations in developing a public health response to pandemic influenza, 2007
   
2. Sarah Marchand, Priority-Setting for a Flu Pandemic: Person Trade-Off Exercises (ms, 2006; by permission). Posted on the website.
3. Sheri Fink, The Deadly Choices at Memorial. ProPublica/New York Times, August 27, 2009
   

Further reading:

1. Amy Fairchild et al, “The Challenge Of Mandatory Evacuation: Providing For And Deciding For?. Health Affairs 25 (4), 2006, pp 958-967.

Monday March 7: Responsibility for Health

[Term paper due]

1. Daniel Wikler, Personal and Social Responsibility for Health. In Sudhir Anand, Fabienne Peter, and Amartya Sen, Public Health, Ethics, and Equity (2006). Course website.
2. Shlomi Segall, In solidarity with the imprudent: A defense of luck egalitarianism.
   Social Theory and Practice33(2) 2007, pp. 1-22

Further reading:

1. Harald Schmidt, Kristen Voigt, and Daniel Wikler, “Carrots, Sticks, and Health Care Reform — Problems with Wellness Incentives”. New England Journal of Medicine Dec. 30, 2009
2. Howard Leichter, A New Perspective on Health: the second public health revolution. In his Free to Be Foolish, 1991.
   
3. Roger Scruton, WHO, What, and Why: Transnational Government, Legitimacy and the World Health Organization (Institute of Economic Affairs, 2001)
   

Wednesday March 9: Research with Human Subjects

[Final Exams posted tonight; due by 11:59 p.m. March 12]

1. Hans Jonas, Philosophical reflections on experimenting with human subjects.
   In Hans Jonas, Philosophical Essays: From Ancient Creed to Technological Man. Englewood Cliffs: Prentice-Hall, 1974
   
2. Leo Alexander, “Medical Science under Dictatorship”.New England Journal of Medicine 1949:241:39-47
3. Dan Brock and Daniel Wikler, “Ethical Issues in Resource Allocation, Research, and New Product Development”. In Dean T. Jamison et al. Disease Control Priorities in Developing Countries.
   Oxford University Press (Chapter 14, pp. 265-270 only in 1993 version)