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Briefing Note For up-to-date relating to healthy public policy that means. ethical theory, we begin by discussing what at first glance. Since is a normative utilitarian is not evident as it as may presumed link between public health practice and four questions, showing, in particular, that the document, we will try to respond briefly to these utilitarianism play in public health? In this short beenhas critiqued? And what role should strengths? What the are main ways in which it But what is utilitarianism? What are its main should not do in the of area public health. by extension, for determining what should we and of public a theory for evaluating and justifying the ethics would therefore seem to be well suited as health. According to these authors, utilitarian particularly intuitive to those working in public assert that the utilitarian perspective seems (2015, p. individuals possible, ideally the entire population” of persons) of the maximum number of status (something that contributes to the well utilitarian because it seeks to preserve the health Maestre write that “public health i For Royo Nixon & Forman, 2008; Rothstein, 2004; utilitarian ethics (Holland, 2007; Horner, 2000; interventions and programs are rooted in Many authors that argue Introduction publichealth ethics. theories and approaches that important are to practitioners to some concepts, values, , of a series of papers intended to introduce specialist in ethics to do so. This document is part on everyday practice. One not does have to be One way is by ethicalusing concepts to shed light challengesin publichealth practiceand policy? How can we perceive and address ethical example, Royo- - Bordon

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o seem seem - a for example. They might have to respect promote or solidarity, individual and institutional agents (Pettit,1993). right thing to do, with respect for the , for The theory of the right determines what is the , for example, may have moral . may notice that in these four conceptions there is . self moral value (Pettit, 1993). Autonomy, friendship, ) defines the good, i.e.,that which has theory of the good (also called value theory or and a theory of the right (Rawls, 1971). The two essential components: a theory of the good Normative ethical theories generally incorporate theories, utilitarianism, and deontological policies (Dawson, 2010, p. morality of actions, interventions and public guide decision making and justify evaluate or the individually and collectively. Such a theory can morally, we should and should not do, both moral theory) is a systematic conception of what, A normative ethical theory (also referred to as What is a normative ethical theory? present the four main conceptions of ut different versions of utilitarianism. willWe briefly of utilitybeen proposed, have giving rise to utilitarianism in the 19th century, many definitions utility? Since the first systematic formulations of value, is For utilitarianism, the good, that or which has T obligation, actions, programs and policies. moralOur utilitarianism, according utility. Thus, maximizes to which that identifies the good with utility and the Utilitarianism is a normative ethica theory l that utilitarianism?is What normative ethical theories HE GOOD IS UTILITY - respect, solidarity, health, well

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2 Briefing Note Utilitarianism in Public Health

an from the immediate and pleasure- THE RIGHT IS THAT WHICH MAXIMIZES THE GOOD related to the longer-term, rational and planning for overall interests or well-being related. The other essential component of a normative ethical theory is a theory of the right which determines what Utility is pleasure and the absence of people and institutional agents must do with respect In its earliest formulations, utility (or the good) was to the good. Utilitarian theories are consequentialist associated with pleasure and the absence of in that they determine the moral value of actions, suffering, and (or the bad) was associated with policies or institutional arrangements with reference suffering and the privation of pleasure (Bentham, solely to their consequences (Honderich, 1995) and 1961 [1789]; Mill, 1998 [1861]; Sidgwick, 1907 not, for example, with reference to certain inherent [1874]). characteristics of actions or to the of moral agents. In other words, for consequentialists, and thus for utilitarians, no action is either right or wrong Utility is the satisfaction of preferences (good or bad) in itself. Instead actions are conceived Some authors view utility instead in terms of the of as instruments that may be more or less useful, satisfaction of individual preferences (Hare, 1981; more or less effective and efficient, for doing good. In Harsanyi, 1977; Singer, 1993). This is probably the the case of utilitarianism, the moral value of actions, most influential approach today (Goodin,1993) and policies, practices or rules is therefore determined on the one underpinning cost-benefit economic the basis of their effects on the amount of utility in analyses that make particular use of the willingness- the world (Honderich, 1995). to-pay method to identify the preferences of individuals (Roberts & Reich, 2002).1 To determine the value of various options being considered, utilitarians apply the utility calculus. Utility is the satisfaction of informed or rational The utility calculus determines the net amount of preferences utility produced by an action or policy. The net utility Utility has also been defined in terms of the is the sum of the utility produced (e.g., the sum of preferences that individuals would have if they had resulting from the action) minus the sum of all the and cognitive abilities needed to the utility lost (e.g., the resultant suffering or loss of make informed choices (Brandt, 1979). Such a pleasures). conception of utility thus moves away from preferences that individuals have, for example, when Utilitarianism is said to be impartial, because each they are under the influence of alcohol or drugs, or “unit” of utility (each satisfied preference, for when they are about to make a choice and do not example) holds equal weight in the utility calculus. In have all the relevant information. other words, the pleasures, preferences or interests of each person must be taken into account and they Utility is the satisfaction of interests have the same value, regardless of whose they are (Honderich, 1995). Because utilitarianism requires Moving still further away from preferences expressed the maximization of utility, the right thing to do is not by individuals, some utilitarian theories define utility simply that which produces utility, but that which, as the satisfaction of certain basic interests shared from an impartial standpoint, produces the most by all, such as being healthy or having a dwelling. utility. These interests concern “resources that will be necessary for people to have before pursuing any of But how does one perform the utility calculus and the more particular preferences that they might thus determine what should be done? There are two happen to have” (Goodin, 1993, p. 244). main ways of calculating utility, giving rise to two types of utilitarianism: and .

1 For a more detailed explanation of the links between implications of economic , see Rozworski and utilitarianism and various methods of economic , as Bellefleur (2013) and Rozworski (2014). well as a discussion and a critique of the main ethical

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Briefing Note 3 Utilitarianism in Public Health

Act utilitarianism Summary – What is utilitarianism? Most utilitarian theories require that each action or Utilitarianism is a normative ethical theory policy be examined to determine which would according to which our moral obligation is to maximize utility in a specific context. The action or maximize the good, i.e., utility. Utility is defined in policy that produces the greatest net utility is, terms of pleasure and suffering, or the satisfaction therefore, the one that is morally obligatory. Since of preferences or interests. According to act acts are directly subjected to the utility calculus, the utilitarianism, our moral obligation is to pursue the terms direct and act action, intervention or policy that would maximize utilitarianism are used (Honderich, 1995). utility in the specific context in which such an option is being considered. According to rule Rule utilitarianism utilitarianism, on the other hand, our moral Some utilitarian theories require instead that actions obligation would be to pursue the option that or policies comply with rules which, when followed, complies with a rule that, in general, maximizes generally allow utility to be maximized. Actions and utility. policies being considered are thus morally obligatory (or right) not when they maximize utility in a specific What are utilitarianism’s main context, but when they conform to rules which, in strengths? general, maximize utility. Since actions or policies are not directly subjected to the utility calculus (which instead is applied to the rules with which actions and SIMPLE AND INTUITIVE policies must comply) the terms indirect The simplicity of utilitarianism derives from the fact consequentialism and rule utilitarianism are used that it is an ethical theory that relies on a single (Honderich, 1995). : the principle of utility. Utilitarianism, therefore, does not require a procedure for Let us consider a simple example that illustrates the arbitrating between different principles that may between these two theories of the right. In enter into conflict (for example, autonomy and equity, certain contexts, lying to a patient could prove to be or the right to privacy and the right to information), the option that maximizes utility, for example when a and is spared the arbitrariness and complexity that can spare a patient unnecessary stress and when such a procedure may seem to introduce into moral there is no risk of its being discovered. Act evaluation (Beauchamp & Childress, 1994). utilitarianism would lead to the conclusion that it is Supported by quantitative methods for calculating therefore morally obligatory to lie under such utility, utilitarianism thus offers an ethical approach circumstances. Rule utilitarianism would instead which tends to issue clearer, simpler and more necessitate the following line of inquiry: would a rule precise answers than rival approaches. allowing one to lie to patients produce, in general, more utility than another rule that, for example, Its simplicity also derives from its theory of the right, prohibits lying to patients? Depending on the result which can be summed up as the requirement to of the utility calculus applied to these two rules, a maximize good in the world. And this is also very rule utilitarian might conclude that patients should intuitive (Kymlicka, 2002; Rawls, 1971). Indeed, it is not be lied to, even in cases where a lie would commonly accepted that it is sometimes better to produce more utility. suffer a little, by regularly visiting a dentist for example, or even to deny oneself the satisfaction of certain preferences today, by studying for example, in order to have more pleasure or satisfy more preferences later. It is also very intuitive to weigh advantages and disadvantages before acting and to choose the option that provides the greatest net benefit.

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EVERYONE’S UTILITY IS TREATED EQUALLY UTILITARIANISM CAN JUSTIFY INFRINGING ON INDIVIDUAL PREFERENCES TO PROMOTE A Utilitarianism is an impartial ethical theory. Thus, the utility calculation which is applied to every action or rule treats with strict equality the pleasure/suffering, In seeking to maximize utility, utilitarianism can preferences or interests of all those who may be justify the promotion and protection of a common or affected. The objective is to maximize utility in good even when it is necessary to infringe general and not only or primarily the utility of those on certain individual preferences or moral “rights.” preferred by an agent or a social group (Beauchamp Thus, utilitarianism could morally justify the forced & Childress, 1994). Utilitarianism, in particular when quarantine of people refusing to get vaccinated it is applied to social and political decisions, can thus during a pandemic, or even oblige them to get be viewed as an ethical theory which treats vaccinated if this option would maximize utility. individuals fairly by taking into account the utility of each and treating it on a strictly equal basis Depending on one’s perspective, this characteristic (Kymlicka, 2002). of utilitarianism can be thought of as one of its strengths (if one thinks that the common good must UTILITARIANISM IS “A STRONG WEAPON” FOR sometimes take precedence over the individual’s CALLING INTO QUESTION THE CONCENTRATION OF “right” to autonomy or privacy, for example) or as RESOURCES AND POWER (KYMLICKA, 2002, P. 12) one of its weaknesses (if one thinks, conversely, that individuals should be better protected from Utilitarianism implies that any concentration of constraints that may be placed on them on behalf of resources and power in the hands of a minority is a common good). For the moment, suffice it to stress morally unjustified unless it allows utility to be that a utilitarian perspective can justify taking action maximized. By proposing methods for calculating or in cases, among others, where a “minor” quantifying this utility, utilitarians have, in effect, infringement of individual interests would produce designed an accountability test for those who significant gains in utility at the population level possess such power or resources. In doing so, (Beauchamp & Childress, 1994). utilitarians have provided the less well-off with a tool for judging the fairness of the privileges granted to What are the main criticisms of the most affluent. utilitarianism? Utilitarianism can have very significant distributive implications, particularly because of the diminishing UTILITARIANISM IS TOO DEMANDING of certain resources. In other words, the utility someone derives from the first dollar they According to utilitarianism, we have a moral can spend (or the first apple they can eat) in a day is obligation to always act from an impartial standpoint much greater than the utility they derive from the so as to generate the most utility, or to always follow millionth dollar (or the millionth apple). Utilitarianism the rules which allow us to do so. This is a very can thus justify a massive redistribution of the demanding proposition, too demanding for many. resources of the most affluent, directing these toward Beauchamp and Childress (1994), for example, write the poorest, who will be able to derive greater utility that utilitarians ask “that we act like saints who are from them. without personal interests and goals” (p. 54), because these interests and goals have no particular When it originated, in the 19th century, in the context moral status for utilitarians. In other words, for of a where resources were concentrated in utilitarians, there is no more justification, at least the hands of a minority, utilitarianism thus offered a a priori, for pursuing our own goals or for helping our critique of society that could be characterized as friends, our children, our patients or our community progressive and was a source of inspiration and than for pursuing the goals of others or for helping justification for social and health reforms that strangers. This is why utilitarianism is referred to as benefited the majority of the population (Kymlicka, an agent-neutral theory. 2002).

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Briefing Note 5 Utilitarianism in Public Health

This criticism of the impartial maximization of utility “UTILITARIANISM DOES NOT TAKE SERIOUSLY THE probably holds more weight when utilitarianism is DISTINCTION BETWEEN PERSONS” (RAWLS, 1971, used to guide the decisions and actions of P. 27) individuals than when it serves solely to evaluate public policies and institutional arrangements. In the We stated above that utilitarianism is intuitive, in first case, it can indeed seem strange and overly particular, because it generalizes to all decisions the demanding to assign no special status to personal principle according to which it is rational for an relationships or to goals that individuals wish to individual to accept a small amount of suffering so as pursue. On the other hand, demanding that our to obtain greater pleasure. According to Rawls, “[t]he public policies be impartial and that they maximize principle of choice for an association of men is utility seems from the outset less strange and could interpreted as an extension of the principle of choice even be regarded as one of utilitarianism’s strengths. for one man” (Rawls, 1971, p. 24). However, there is When the scope of utilitarianism is limited to public a significant difference between choices that concern policies and institutional arrangements, this is a single individual and those that concern a plurality referred to as political utilitarianism (Kymlicka, of persons. When an individual chooses to suffer a 2002). little to obtain greater pleasure, the result is a net increase in utility for that individual, who both THE UTILITY CALCULATION IS NOT AS SIMPLE AS IT sustains the loss and benefits from the gain. When a SEEMS policy that imposes a small amount of suffering so as to create a greater amount of pleasure is adopted, According to the utilitarian approach, one must the net utility also increases, but some people may measure the utility produced by various options and suffer the loss while others benefit from the gain choose the one that produces the most utility. While (Kymlicka, 2002, p. 52, note 16). This is what leads the principle is simple, its implementation can prove Rawls to conclude that utilitarianism does not “take difficult. Indeed, to calculate utility, one must identify, seriously the distinction between persons” (Rawls, measure and compare the effects of actions or rules 1971, p. 27). on types of good that sometimes differ greatly from each other (varying types of pleasure and suffering, According to Mackie, “on a utilitarian view, preferences or interests). Added to the difficulties transferring a satisfaction from one person to associated with comparing different are those another, while preserving its magnitude, makes no associated with comparing different persons, who morally significant difference” (1984, p. 87). In other may react differently to the same good or the same words, what matters to a utilitarian is the net utility, evil. For example, a permanent knee injury can and not its distribution among individuals or groups. represent a decrease in utility that is different for an The option that maximizes utility will always be just athlete than for an office worker. because utilitarianism does not include a principle of independent of the principle of utility. For When one is comparing and evaluating policy Rawls, given that certain decisions (including policy options that affect many people and touch on decisions) affect a plurality of persons, the ethics different facets of their lives, the complexity of the guiding those decisions must include an independent utility calculation becomes evident. Given a specific principle of justice that can counterbalance the budget, for example, will the most utility be produced principle of utility. Accepting this argument amounts by the addition of a certain number of social housing to a rejection of the idea that ethics can depend units, of a certain number of psychoeducators in solely on the principle of utility and, by extension, of schools or of a certain number of hospital beds? If utilitarianism. the utility of different options cannot be calculated and compared due to excessive complexity, lack of data, or for other reasons, then utilitarianism loses its appeal as a practical guide to decision making. Although one of utilitarianism’s strengths in the Moreover, some authors criticize utilitarianism for fact that it can be a strong weapon for calling into being too cognitively demanding for moral agents question the concentration of resources and power in and for leading to a kind of paralysis during decision the hands of a minority, the reverse side of this making (Friedman, 1989). strength is that utilitarianism can be used to justify the oppression of minorities if this increases utility for

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6 Briefing Note Utilitarianism in Public Health

the majority. This is the source of the idea that utilitarian framework (Beauchamp & Childress, utilitarianism could justify a tyranny of the majority. 1994). It is this type of criticism, among others, that This criticism, which ties in with the previous one, is led to the evolution of the different conceptions of perhaps strongest when applied to “the comparison utility as outlined on pages 1-2 above (in the section of small benefits to many individuals with large entitled “The good is utility”) from the more benefits to a much smaller number of individuals” immediate pleasure/pain to the more rational (Brock, 2009, p. 119), as when the utility produced interest-based conceptions of utility. by the relief of many headaches is compared to that produced by a few heart transplants. Based solely on the principle of utility, it is difficult to justify excluding from the utility calculus the To illustrate this criticism using an example from pleasures of a sadistic person or discriminatory or another political field, consider the opposition racist preferences, for example. Similarly, but between the preference for driving quickly and the inversely, it is difficult to avoid assigning greater preference for not being injured while crossing the moral significance to satisfying the preferences of street on foot. Regardless of the amount of utility popular people, with large families or many friends, attributed to each preference, if there are enough than to satisfying the preferences of less popular people who prefer to drive quickly, this preference people, with small families and few friends, because will take precedence over the safety of a minority of satisfying the former allows the preferences of many pedestrians. “Thus, utilitarianism not only allows, but others (known as external preferences) to be enjoins, in some circumstances, that the benefit satisfied at the same time (Kymlicka, 2002). It can (utility) of ‘the many’ might be ‘purchased’ at the cost also be difficult to exclude or treat differently so- of the undeserved and uncompensated misery of called “adaptive” preferences, i.e., the preferences of ‘the few’” (Hann & Peckham, 2010, p. 141). persons who have adapted to adverse situations by gradually abandoning preferences that they have THE END CANNOT JUSTIFY ALL MEANS little chance of satisfying (Kymlicka, 2002). We might consider, as just one example, the preferences of Utilitarianism, as a consequentialist theory, evaluates persons belonging to social groups that are the morality of actions or policies solely on the basis subjected to discriminatory social practices, or of their consequences for the amount of utility in the persons who are socially and economically world. The means used to obtain a given quantity of disadvantaged and have therefore abandoned the utility are thus included in the utility calculation, but hope of pursuing higher education or of securing a they have no particular moral status. Thus, the end well-paid job, for example. However, to make can justify the use of means that may seem morally pursuing the satisfaction of adaptive preferences a dubious. Indeed, utilitarianism may call for its moral objective is to run the risk of perpetuating, or proponents to lie, to cause suffering, to constrain even aggravating, situations that would best be people, or to oppress, discriminate against, described as “unjust,” but which are difficult to marginalize or stigmatize people, for example, when characterize as such from a utilitarian perspective. such practices maximize utility. For many, the use of certain means cannot be justified by the need to According to some authors, the only way to maximize utility, because these means contravene adequately filter or address such pleasures or other important ethical principles, such as autonomy, preferences is to abandon the utilitarian perspective the right to physical integrity, etc., which have no by including principles other than utility in ethical distinct place in utilitarian thought (Hann & Peckham, reflection, such as a principle of or 2010). of (Beauchamp & Childress, 1994; Rawls, 1971). The weight of this criticism is probably NOT ALL PLEASURES OR PREFERENCES ARE less and less the more that we move from a EQUAL conception of utility as the preferences or pleasures of individuals toward more rational or informed The last critique of utilitarianism presented here preferences or interests. concerns the inclusion of pleasures and preferences which, according to other ethical perspectives, should not be included in the utility calculus, but whose exclusion is difficult to justify within a

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What role should utilitarianism play in evaluated and one of the consequences would be the eviction of current tenants. At other times, public health? more emphasis seems to be placed on the consequences related to the guidelines, rules of Should utilitarian theory be used to guide and conduct or professional standards which will evaluate public health actions, programs and apply to a multitude of cases (as with indirect interventions? In other words, should public health consequentialism), such as when establishing maximize utility and should it only maximize utility? guidelines that restaurant inspectors will have to We will examine three possible responses. observe to ensure safety.

PUBLIC HEALTH SHOULD ADOPT UTILITARIANISM 3. As with utilitarianism, public health seeks to achieve an effect at the population level and Those who would answer “yes” to the question of not, initially, at the individual level. It follows that whether public health practice should only maximize public health sometimes calls for interventions utility will likely stress the strengths of utilitarian that negatively affect some individuals, but thought along with four characteristics of improve the collective health of the population utilitarianism that seem consistent with public health (Cribb, 2010; Nixon & Forman, 2008). practice: 4. As with utilitarianism, the justification for 1. As with utilitarianism, one of the aims of public -led public health actions, programs health is to maximize the presence of a good, and interventions is usually based on an namely the health of the population. Public health impartial point of view. Public health authorities actions are thus evaluated, at least in part, on the and practitioners usually justify their actions on basis of the gains and losses they entail for the the basis of their populational effects and not, for health of the population (Cribb, 2010; Holland, example, on the basis of their effects on people 2007 and 2010). Several tools have been with whom they have personal relationships or on 3 developed for carrying out such evaluations, groups that they might favour. including economic tools such as the quality- adjusted life years (QALY) index or the disability- These four characteristics, in addition to the simple adjusted life years (DALY) index, which are and intuitive nature of utilitarianism, probably explain central to cost/utility economic evaluations.2 the attraction of the utilitarian perspective for public Effectiveness and efficiency are thus important health actors. factors in evaluating actions, programs and interventions as objectively as possible, both in PUBLIC HEALTH SHOULD NOT ADOPT public health and for utilitarians. UTILITARIANISM

2. In the field of public health, as in utilitarian Conversely, those who would answer “no” to the thought, special attention is paid to question of whether public health practice should consequences. In public health, emphasis is only maximize utility will likely stress the previously placed on the health of the population. mentioned criticisms of utilitarianism, as well as three Sometimes more emphasis seems to be placed major differences between the goals and practices of on the consequences of a specific act or public health with those of utilitarianism: intervention (as with direct consequentialism), such as when the positive and negative effects 1. Health and utility are two concepts with multiple associated with the decision to declare a specific meanings which may overlap to varying degrees, building unsuitable for habitation are being but which are not usually treated as synonyms. Thus, if health is only one aspect of utility or if

2 Although economic evaluations that seek to determine the cost investing, for example, more resources in improving the health per QALY gained are called “cost/utility evaluations,” the way of hard-to-reach populations. Impartiality, that is, equal utility is conceived of here is quite different from the way it is treatment of the utility of each person, and equity are in tension conceived of in utilitarianism. To learn more about the here, which suggests the need for a principle of justice or difference between the utility of utilitarians and the QALY of equity independent of the utility principle in public health; health economists, see, for example, Dolan (2001). whereas, within utilitarianism, equitable and impartial treatment calls for equal treatment using a calculation designed to 3 It is important to note that public health authorities and maximize utility. In other words, this tension does not exist practitioners sometimes assign greater importance to certain within utilitarianism. groups within the population for reasons relating to equity, by

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8 Briefing Note Utilitarianism in Public Health

utility is only one aspect of health, then population health (and for health inequalities). maximizing health will not produce the same Thus, one does not believe it should be purely result as maximizing utility (Holland, 2007). In consequentialist, and by extension, utilitarian. fact, public health advocates are accused of “healthism” when they forget that health is not the PUBLIC HEALTH SHOULD ADOPT THE UTILITY only good that can have moral value and, PRINCIPLE, BUT NOT UTILITARIANISM moreover, that it is not a good that necessarily always takes precedence over others (Cribb, The approach which seems to prevail in public health 2010, p. 25). ethics is positioned somewhere between the 2. Next, while the (or one) purpose of public health adoption and the rejection of utilitarian theory. It is to maximize the health of the population, it is consists of retaining the utility principle, while rejecting the utilitarian claim of being able to base acknowledged by many that another of its the entire field of public health ethics on this single purposes is to reduce health inequalities (Agence de la santé et des services sociaux de principle (e.g., Baum, Gollust, Goold, & Jacobson, Montréal, 2012; Butler-Jones, 2008; Powers & 2007; Childress, 2013; Childress et al., 2002; Faden, 2006). As soon as one claims the ability Holland, 2007; Massé, 2003; World Health to justify interventions or policies that are Organization, 2007). Strictly speaking, this approach somewhat less effective at improving the general is equivalent to a rejection of utilitarianism, because level of population health, but that reduce health the maximization of utility alone is no longer inequalities, one must concede that public health advocated (Honderich, 1995). The utility principle is not guided solely by a principle of maximization effectively loses its status as a fundamental and (of health). Thus, public health ethics cannot be primary principle and is placed instead on an equal based on a single principle, as is utilitarianism. If footing with other principles (equity, justice, one considers that public health has two autonomy, etc.) that must also be taken into independent purposes, namely, maximizing consideration during ethical reflection and population health and reducing health inequalities deliberation. (Powers & Faden, 2006), then public health ethics should include, at the minimum, a Thus, one form or another of the utility principle is found in many public health ethics frameworks. It is principle of equity or justice in addition to a principle of health maximization. often referred to as a principle of the proportionality of risks, costs, burdens and benefits (Beauchamp & 3. Finally, although special attention is focused on Childress, 1994; Schröder-Bäck, Duncan, Sherlaw, the consequences of public health actions, Brall, & Czabanowska, 2014; Selgelid, 2009 Singer programs and interventions, evaluation of the et al., 2003). Sometimes, its characteristics are latter is rarely limited to consideration of their divided among several principles (e.g., principles of effectiveness and efficiency at fostering one or effectiveness and efficiency), but it is always more goals. Therefore, public health practice accompanied by other principles that can limit its cannot be considered purely consequentialist. application and relevance during the evaluation of This does not mean that it should not be; specific cases. however, to reflect public health practice, most frameworks for public health ethics include This principle-based approach is inspired by certain values, respect for which is intended to , an approach developed by Beauchamp guide the choice of means used to achieve and Childress (1994) for biomedical or clinical ethics. objectives. Often included, for example, are It aims primarily to combine the strengths and respect for the autonomy of individuals and neutralize the weaknesses of various principles communities, or the fair and equitable treatment taken in isolation, leaving the relevant actors to of individuals and groups. If one views such balance the various principles in specific cases.4 values as important to public health, then one does not believe that public health should focus solely on the consequences of its practices for

4 To learn more about principlism, its strengths and weaknesses, and its ties to public health frameworks, see Keeling and Bellefleur (2016).

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How to use this document References

For public health actors who use ethics frameworks Agence de la santé et des services sociaux de that incorporate the utility principle, this document Montréal. (2012). 2011 Report of the director should help you to: of public health. Social inequalities in health in Montréal. to date, Montréal, • Understand the significance others attach to the Québec. Retrieved from: https://santemontre utility principle during deliberations; al.qc.ca/fileadmin/user_upload/Uploads/tx_a • Determine what the utility principle could be used sssmpublications/pdf/publications/978-2- to justify based on different conceptions of utility 89673-131-2.pdf (pleasure/suffering, informed, rational or existing preferences, interests) and of obligation (act or Baum, N. M., Gollust, S. E., Goold, S. D., & rule utilitarianism); Jacobson, P. D. (2007). Looking ahead: Addressing ethical challenges in public • Identify the strengths and weaknesses of the health practice. Journal of , Medicine & utility principle when reflecting on and discussing Ethics, 35(4), 657-667. doi: 10.1111/j.1748- a specific case; 720X.2007.00188.x. Retrieved from: http://deepblue.lib.umich.edu/bitstream/handl • Judge the relevance of the utility principle for a e/2027.42/75478/j.1748- specific case; 720X.2007.00188.x.pdf?sequence=1&isAllo • Arbitrate between the requirements of the utility wed=y principle and the requirements of other principles considered relevant to a given situation. Beauchamp, T. L. & Childress, J. F. (1994). Principles of biomedical ethics. Fourth This document can also help public health actors to edition. Oxford: . perceive and critique the limitations of a utilitarian approach to public health or, for those who have Bentham, J. (1789, 1961). An introduction to the principles of morals and legislation. Garden adopted such an approach, to review their City: Doubleday. conception of utilitarianism in response to the criticisms raised. Brandt, R. B. (1979). A theory of the good and the right. Oxford/New York: Clarendon Press: Oxford University Press.

Brock, D. W. (2009). Ethical issues in applying quantitative models for setting priorities in prevention. In A. Dawson & M. Verweij (Eds.), Ethics, prevention and public health (pp. 111-128). Oxford: Oxford University Press.

Butler-Jones, D. (2008). The Chief Public Health Officer’s report on the state of public health in Canada, 2008: Addressing health inequalities. Ottawa: The Public Health of Canada. Retrieved from: http://www.phac-aspc.gc.ca/cphorsphc- respcacsp/2008/fr-rc/pdf/CPHO-Report-e.pdf

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Briefing Note 11 Utilitarianism in Public Health

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Tel: 514 864-1600 ext. 3615 • Email: [email protected] • Twitter: @NCCHPP • ncchpp.ca January 2016 Authors: Olivier Bellefleur and Michael Keeling, National Collaborating Centre for Healthy Public Policy

HOW TO CITE THIS DOCUMENT Bellefleur, O. & Keeling, M. (2016). Utilitarianism in public health. Montréal, Québec: National Collaborating Centre for Healthy Public Policy.

ACKNOWLEDGMENTS The NCCHPP wishes to thank Geneviève Beauregard (Ministère de la Santé et des Services sociaux), Michel Désy (Institut national de santé publique du Québec) and Christian Nadeau (Université de Montréal) for their comments regarding a preliminary version of this document. The National Collaborating Centre for Healthy Public Policy (NCCHPP) seeks to increase the expertise of public health actors across Canada in healthy public policy through the development, sharing and use of knowledge. The NCCHPP is one of six centres financed by the Public Health Agency of Canada. The six centres form a network across Canada, each hosted by a different institution and each focusing on a specific topic linked to public health. The National Collaborating Centre for Healthy Public Policy is hosted by the Institut national de santé publique du Québec (INSPQ), a leading centre in public health in Canada. Production of this document has been made possible through a financial contribution from the Public Health Agency of Canada through funding for the National Collaborating Centre for Healthy Public Policy (NCCHPP). The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada. Publication N°: 2741 This document is available in its entirety in electronic format (PDF) on the Institut national de santé publique du Québec website at: www.inspq.qc.ca/english and on the National Collaborating Centre for Healthy Public Policy website at: www.ncchpp.ca. La version française est disponible sur les sites Web du Centre de collaboration nationale sur les politiques publiques et la santé (CCNPPS) au www.ccnpps.ca et de l’Institut national de santé publique du Québec au www.inspq.qc.ca. Reproductions for private study or research purposes are authorized by virtue of Article 29 of the Copyright Act. Any other use must be authorized by the Government of Québec, which holds the exclusive intellectual property rights for this document. Authorization may be obtained by submitting a request to the central clearing house of the Service de la gestion des droits d’auteur of Les Publications du Québec, using the online form at http://www.droitauteur.gouv.qc.ca/en/autorisation.php or by sending an e-mail to [email protected]. Information contained in the document may be cited provided that the source is mentioned. LEGAL DEPOSIT – 4th QUARTER 2020 BIBLIOTHÈQUE ET ARCHIVES NATIONALES DU QUÉBEC LIBRARY AND ARCHIVES CANADA ISBN: 978-2-550-87859-9 (FRENCH PDF) ISBN: 978-2-550-87860-5 (PDF)

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