Ethical Theories, Principlism and the Discourse Ethics in Public Health

RAYMOND MASSÉ Université Laval Quebec City, Canada

JASP Quebec City, November 24, 2010 1 SCENARIOSCENARIO FORFOR DELIBERATIONSDELIBERATIONS ONON ETHICSETHICS „ HIVHIV partnerpartner notificationnotification programprogram

„ DoDo wewe oror dodo wewe notnot needneed toto obtainobtain consentconsent fromfrom thethe indexindex casecase beforebefore beginningbeginning toto informinform hishis oror herher sexualsexual partners?partners?

„ IfIf aa professionalprofessional hashas aa mandatemandate toto protectprotect populationpopulation health,health, isis itit ethicallyethically legitimatelegitimate forfor themthem toto ignoreignore thethe indexindex casecase whowho hashas refusedrefused toto letlet certaincertain partnerspartners bebe contactedcontacted andand informed?informed?

„ IsIs itit ethicalethical toto contactcontact sexualsexual partnerspartners knowingknowing thatthat itit willwill sometimessometimes bebe difficultdifficult toto concealconceal thethe identityidentity ofof thethe indexindex casecase??

JASP Quebec City, November 24, 2010 2 ARGUMENTSARGUMENTS VOICEDVOICED BYBY DELIBERATIONDELIBERATION PARTICIPANTSPARTICIPANTS

„ SpeakerSpeaker #1#1 :: ““AsAs aa professionalprofessional withwith aa mandatemandate toto protectprotect populationpopulation health,health, II feelfeel thatthat therethere isis aa clearclear imperativeimperative toto informinform sexualsexual partners,partners, eveneven ifif therethere isis aa riskrisk thatthat thethe indexindex casecase willwill bebe identifiedidentified andand bebe thethe victimvictim ofof socialsocial stigmatizationstigmatization asas someonesomeone whowho isis HIVHIV--positivepositive oror transmittingtransmitting illness.illness.””

„ IMPLICITIMPLICIT PRINCIPLEPRINCIPLE „ Ethics:Ethics: dutyduty toto protectprotect healthhealth

JASP Quebec City, November 24, 2010 3 ARGUMENTSARGUMENTS VOICEDVOICED BYBY DELIBERATIONDELIBERATION PARTICIPANTSPARTICIPANTS

„ SpeakerSpeaker #2#2 ““II wouldwould makemake thethe samesame argumentsarguments asas X,X, butbut II speakspeak asas anan individual.individual. II cannotcannot letlet myselfmyself bebe partyparty toto thethe virusvirus beingbeing transmittedtransmitted toto victimsvictims whowho areare keptkept inin thethe darkdark aboutabout theirtheir partnerpartner’’ss HIVHIV--positivepositive status.status. II wouldwould feelfeel personallypersonally responsible.responsible.””

„ IMPLICITIMPLICIT PRINCIPLEPRINCIPLE „ ResponsibilityResponsibility

JASP Quebec City, November 24, 2010 4 ARGUMENTSARGUMENTS VOICEDVOICED BYBY DELIBERATIONDELIBERATION PARTICIPANTSPARTICIPANTS

„ SpeakerSpeaker #3#3 ““PeoplePeople withwith HIVHIV runrun thethe riskrisk ofof seeingseeing theirtheir liveslives destroyeddestroyed onceonce theirtheir HIVHIV-- positivepositive statusstatus becomesbecomes widelywidely known.known. AsAs professionals,professionals, wewe havehave aa responsibilityresponsibility toto protectprotect them;them; theythey areare sufferingsuffering enoughenough asas itit is.is. AtAt leastleast wewe shouldnshouldn’’tt addadd toto theirtheir suffering.suffering.””

„ IMPLICITIMPLICIT PRINCIPLEPRINCIPLE „ Compassion:Compassion: harmharm reductionreduction

JASP Quebec City, November 24, 2010 5 ARGUMENTSARGUMENTS VOICEDVOICED BYBY DELIBERATIONDELIBERATION PARTICIPANTSPARTICIPANTS

„ SpeakerSpeaker #4#4 ““Nowadays,Nowadays, allall citizenscitizens areare awareaware ofof thethe risksrisks associatedassociated withwith unprotectedunprotected sexualsexual relations.relations. AllAll independentindependent citizenscitizens havehave aa responsibilityresponsibility toto protectprotect themselves.themselves. IfIf everyoneeveryone protectedprotected themselves,themselves, HIVHIV-- positivepositive peoplepeople wouldnwouldn’’tt bebe ableable toto infectinfect anyone,anyone, eveneven ifif theythey didndidn’’tt revealreveal theirtheir HIVHIV--positivepositive status.status. HIVHIV--positivepositive peoplepeople havehave aa rightright toto confidentialityconfidentiality andand privacy,privacy, andand thatthat needsneeds toto comecome first.first.””

„ IMPLICITIMPLICIT PRINCIPLEPRINCIPLE „ RespectRespect forfor privacy:privacy: autonomyautonomy

JASP Quebec City, November 24, 2010 6 ARGUMENTSARGUMENTS VOICEDVOICED BYBY DELIBERATIONDELIBERATION PARTICIPANTSPARTICIPANTS

SpeakerSpeaker #5#5 ““Anyway,Anyway, thethe programprogram evaluationsevaluations showshow thatthat HIVHIV infectioninfection couldcould bebe controlledcontrolled moremore effectivelyeffectively ifif wewe gavegave prioritypriority toto keepingkeeping thethe HIVHIV statusstatus ofof infectedinfected personspersons confidential.confidential. ThisThis isnisn’’tt aboutabout values,values, itit’’ss aboutabout whatwhat isis effective.effective. WhatWhat mattersmatters isis thethe longlong--termterm resultsresults inin termsterms ofof transmissiontransmission ofof thethe virus.virus.””

IMPLICITIMPLICIT PRINCIPLEPRINCIPLE „ Utilitarian:Utilitarian: utilityutility

JASP Quebec City, November 24, 2010 7 AA CONSTANTCONSTANT ININ ETHICALETHICAL DELIBERATIONSDELIBERATIONS „ WhenWhen itit comescomes timetime toto taketake aa clearclear position,position, eacheach professionalprofessional putsputs forwardforward anan ultimateultimate argumentargument thatthat takestakes thethe formform ofof aa principle.principle.

„ WeWe lacklack aa sharedshared vocabularyvocabulary forfor ethics.ethics.

„ WeWe needneed aa listlist ofof fundamentalfundamental valuesvalues (for(for QuebecQuebec society)society) thatthat wewe cancan allall acceptaccept asas basicbasic guidesguides forfor action.action.

JASP Quebec City, November 24, 2010 8 AnAn ethicsethics ofof publicpublic healthhealth needsneeds toto combinecombine severalseveral theoreticaltheoretical approachesapproaches

„ OntologicalOntological approachapproach:: searchsearch forfor fullfull happiness,happiness, thinkingthinking aboutabout thethe purposepurpose ofof life,life, manman’’ss placeplace inin nature,nature, societysociety „ NarrativeNarrative ethicsethics:: bottombottom--upup approach,approach, concernconcern forfor thethe contextcontext ofof life,life, locallocal constructionconstruction ofof meaningmeaning „ CodeCode ofof ethicsethics:: professionalprofessional’’ss moralmoral responsibilities,responsibilities, dutyduty toto ensureensure preventionprevention „ UtilitarianUtilitarian:: BalancingBalancing costscosts andand benefitsbenefits (economic,(economic, health,health, social,social, political,political, etc.)etc.) „ EmpiricalEmpirical andand descriptivedescriptive ethicsethics:: taketake intointo accountaccount thethe mainmain valuesvalues ofof thethe populationspopulations targetedtargeted byby programsprograms „ EthicalEthical relativismrelativism andand pragmatismpragmatism:: raiseraise questionsquestions aboutabout ethnocentricethnocentric andand dogmaticdogmatic biasesbiases inin thethe principlesprinciples andand valuesvalues chosenchosen

JASP Quebec City, November 24, 2010 9 PUBLICPUBLIC HEALTHHEALTH ANDAND NORMATIVENORMATIVE ETHICSETHICS -- 11 „ ForFor sixsix reasons,reasons, ethicsethics cancan onlyonly bebe normative:normative:

„ 1) We can only follow an empiricist and relativistic ethics at the risk of adopting the attitudes of: „ the “Conservative thug” „ the “Complacent democrat” „ the influence of “moral communities,” lobby of “comprehensive egoism” (Steven Kautz)

„ 2) Must be based on a premise of social justice: treating everyone equitably

„ 3) The fundamental values and principles on which it will be based must be explicit, clearly identified and defined.

JASP Quebec City, November 24, 2010 10 PUBLICPUBLIC HEALTHHEALTH ANDAND NORMATIVENORMATIVE ETHICSETHICS -- 22 „ 4)4) AnAn implicitimplicit normativitynormativity alreadyalready guidesguides decisionsdecisions inin publicpublic health.health.

„ 5)5) ““ItIt isis anan illusionillusion toto thinkthink thatthat whatwhat wewe saysay isis notnot basedbased onon aa moralmoral orientationorientation thatthat wewe believebelieve isis justjust”” (translation,(translation, Taylor,Taylor, 1998).1998).

„ 6)6) PublicPublic healthhealth mustmust bebe ableable toto assumeassume andand defenddefend thethe ethicalethical positionspositions itit takes,takes, whetherwhether theythey areare consciousconscious oror not.not. ““TheseThese challengeschallenges requirerequire anan analysisanalysis basedbased onon anan ideologicalideological oror normativenormative commitmentcommitment”” (translation,(translation, GuttmanGuttman,, 2000).2000).

JASP Quebec City, November 24, 2010 11 DOESDOES PRICIPLISMPRICIPLISM REPRESENTREPRESENT AA SOLUTION?SOLUTION? „ YES,YES, ONON THETHE CONDITION:CONDITION:

„ 1.1. ThatThat wewe seesee itit lessless asas aa philosophicalphilosophical approachapproach andand moremore asas aa generalgeneral analyticanalytic methodologymethodology

„ 2.2. ThatThat wewe combinecombine itit withwith anan ethicsethics ofof discussiondiscussion toto mitigatemitigate thethe riskrisk ofof fallingfalling underunder thethe swaysway ofof ““expertexpert knowledgeknowledge””

JASP Quebec City, November 24, 2010 12 PRICIPLISM:PRICIPLISM: DEFINITIONDEFINITION #1#1

„ PrinciplesPrinciples ofof BiomedicalBiomedical Ethics:Ethics: BeauchampBeauchamp andand Childress.Childress. SixSix editions,editions, fromfrom 19791979 toto 20082008 „ AA termterm takentaken fromfrom itsits detractorsdetractors „ AnAn appliedapplied approachapproach toto ethicsethics basedbased onon followingfollowing aa limitedlimited numbernumber ofof principlesprinciples derivedderived fromfrom severalseveral schoolsschools ofof philosophyphilosophy „ BasedBased onon fourfour ordersorders ofof principlesprinciples (autonomy,(autonomy, socialsocial justice,justice, beneficencebeneficence andand nonnon--maleficencemaleficence))

JASP Quebec City, November 24, 2010 13 PRINCIPLISM:PRINCIPLISM: DEFINITIONDEFINITION #2#2

„ TheseThese principlesprinciples mustmust bebe ableable toto coco--existexist withwith otherother actionaction guides,guides, suchsuch asas rulesrules andand virtues.virtues.

„ PrinciplesPrinciples constituteconstitute ““guidesguides toto actionaction thatthat areare lessless generalgeneral thanthan theoriestheories butbut moremore generalgeneral thanthan thethe rules,rules, judgmentsjudgments oror casecase studstudiesies toto whichwhich theythey areare appliedapplied”” (translation,(translation, ChildressChildress andand Beauchamp,Beauchamp, 19941994 :79):79)

„ AreAre normativenormative generalizationsgeneralizations thatthat guideguide actionaction

JASP Quebec City, November 24, 2010 14 PRICIPLISM:PRICIPLISM: DEFINITIONDEFINITION #3#3

„ PrinciplismPrinciplism isis notnot aa principleprinciple--drivendriven approach;approach; rather,rather, itit isis principleprinciple--guidedguided (Childress,(Childress, 1994)1994) „ PrinciplismPrinciplism remindsreminds usus thatthat thethe problemproblem inin ethicsethics isis notnot ““havinghaving principles,principles,”” butbut ratherrather followingfollowing themthem dogmatically.dogmatically. „ PrinciplismPrinciplism isis thethe completecomplete oppositeopposite ofof aa dogmaticdogmatic approach.approach.

JASP Quebec City, November 24, 2010 15 PRINCIPLESPRINCIPLES ININ PUBLICPUBLIC HEALTH:HEALTH: E.G.E.G. ETHICALETHICAL FRAMEWORKSFRAMEWORKS DURINGDURING AA PANDEMICPANDEMIC „ TheThe reportreport ““StandStand onon GuardGuard forfor TheeThee”” (2005),(2005), UniversityUniversity ofof TorontoToronto JointJoint CentreCentre forfor Bioethics.Bioethics. „ InIn 2006,2006, thethe PublicPublic HealthHealth EthicsEthics CommitteeCommittee –– ComitComitéé dd’é’éthiquethique enen santsantéé publiquepublique (CESP)(CESP) publishedpublished aa noticenotice onon thethe PublicPublic HealthHealth ComponentComponent ofof thethe QuQuéébecbec PandemicPandemic InfluenzaInfluenza PlanPlan –– HealthHealth MissionMission -- VVoletolet santsantéé publiquepublique dudu PlanPlan QuQuéébbéécoiscois dede luttelutte àà uneune pandpandéémiemie dd’’influenzainfluenza (PQLI)(PQLI).. „ WHO,WHO, 2007,2007, ““EthicalEthical ConsiderationsConsiderations inin DevelopingDeveloping aa PublicPublic HealthHealth ResponseResponse toto PandemicPandemic Influenza.Influenza.”” „ NewNew Zealand,Zealand, ““GettingGetting ThroughThrough Together:Together: EthicalEthical ValuesValues forfor aa Pandemic,Pandemic,”” 2007.2007. „ GreatGreat Britain,Britain, ““RespondingResponding toto PandemicPandemic Influenza:Influenza: TheThe EthicalEthical FrameworkFramework forfor PolicyPolicy andand Planning,Planning,”” 2007.2007.

„ UnitedUnited States,States, ““EthicalEthicalJASP Guidelines GuidelinesQuebec City, November inin 24,PandemicPandemic 2010 Influenza,Influenza,”” 2007.2007.16 CurrentCurrent principlesprinciples andand valuesvalues

„ ValuesValues relatedrelated toto morallymorally justifiablejustifiable treatmenttreatment ofof patients:patients: beneficencebeneficence andand nonnon--maleficencemaleficence,, autonomyautonomy andand privacy.privacy.

„ ValuesValues thatthat frameframe pandemicpandemic policiespolicies andand thatthat applyapply toto communities:communities: justice,justice, solidarity,solidarity, reciprocity,reciprocity, trust,trust, thethe commoncommon good.good.

„ ValuesValues andand principlesprinciples framingframing decisiondecision--makingmaking proceduresprocedures andand communication:communication: transparency,transparency, publicpublic consultationconsultation andand participation,participation, accountability.accountability.

„ ArbitrationArbitration values:values: recognitionrecognition ofof anan obligationobligation toto weighweigh optionoptionss andand arbitrationarbitration inin primaprima faciefacie principlesprinciples == integrationintegration ofof principlismprinciplism

JASP Quebec City, November 24, 2010 17 STRENGTHSSTRENGTHS OFOF PRINCIPLISMPRINCIPLISM FORFOR THETHE MANAGEMENTMANAGEMENT OFOF THESETHESE PRINCIPLESPRINCIPLES „ PrimaPrima faciefacie naturenature ofof principlesprinciples „ SecularSecular naturenature ofof principlesprinciples „ TakesTakes specificspecific contexts,contexts, specialspecial casescases andand specialspecial situationssituations intointo accountaccount „ DefinesDefines ethicsethics asas aa placeplace forfor arbitrationarbitration betweenbetween basicbasic principlesprinciples ofof equalequal valuevalue

JASP Quebec City, November 24, 2010 18 FOURFOUR METHODOLOGICALMETHODOLOGICAL PILLARSPILLARS

„ Explicit list of a limited number of principles that all have a prima facie value.

„ Rejects a mechanistic application of principles and rules as well as any deductive application of one or more principles to cases, which would lead to a tyranny of principles.

„ Proposes balancing, which depends on the weweightight given to competing principles. This weighing of contextual considerations may be either decided at the outset, establishing a hierarchy of stable principles, or established intuitively on a case-by-case basis (intuitive balancing).

„ Specification, which is preceded by a qualitative adjustment of standards to specific cases and is implicitly an integral part of a principlism that is sensitive to contextual issues, circumstancescircumstances and the specific nature of each case.

JASP Quebec City, November 24, 2010 19 WEAKWEAK POINTSPOINTS 11

„ LimitedLimited numbernumber ofof principlesprinciples

„ PrinciplesPrinciples areare selectedselected ratherrather thanthan values.values. ForFor anan ethicalethical frameworkframework basedbased onon keykey valuesvalues

„ VagueVague onon howhow toto identifyidentify thethe mechanismsmechanisms forfor choosingchoosing betweenbetween principles;principles; ethicalethical expertiseexpertise

JASP Quebec City, November 24, 2010 20 LIMITSLIMITS TOTO THETHE NOTIONNOTION OFOF AA ““COMMONCOMMON MORALITYMORALITY”” „ BasedBased onon hypotheticalhypothetical universaluniversal standardsstandards (do(do notnot kill,kill, lie,lie, oror dodo harm;harm; dodo youryour duty,duty, etc.)etc.) andand moralmoral idealsideals (e.g.(e.g. charitablecharitable beneficence)beneficence)

„ IsIs moremore thanthan aa moralitymorality ofof commoncommon sensesense oror aa popularpopular moralitymorality

„ However,However, cancan ethicalethical principlesprinciples bebe derivedderived fromfrom thesethese universal,universal, sharedshared standards?standards?

„ MoreMore thanthan aa listlist ofof principles:principles: aa negotiatednegotiated groupgroup ofof normsnorms andand valuesvalues acceptedaccepted byby allall forfor arbitrationarbitration

„ TheThe ethicsethics ofof publicpublic healthhealth mustmust beginbegin byby distancingdistancing itselfitself fromfrom thethe vainvain debatedebate onon developingdeveloping aa listlist ofof principlesprinciples inin orderorder toto openopen thethe wayway toto anan ethicsethics ofof discussion.discussion. JASP Quebec City, November 24, 2010 21 LIMITSLIMITS OFOF EXPERTEXPERT ETHICISTSETHICISTS

„ MoralMoral philosophersphilosophers areare notnot inin aa betterbetter positionposition toto claimclaim ethicalethical expertise.expertise. „ TheirTheir mandatemandate isis toto promotepromote waysways ofof thinkingthinking andand tailoredtailored reasoning,reasoning, notnot toto provideprovide answers.answers. „ SolveSolve moralmoral problems,problems, butbut alsoalso ““createcreate moralmoral perplexityperplexity wherewhere nonenone existedexisted”” (Caplan,(Caplan, 19891989 :: 74).74). „ MoralMoral expertiseexpertise wouldwould appearappear toto bebe incompatibleincompatible withwith democracy.democracy.

JASP Quebec City, November 24, 2010 22 DISCUSSIONDISCUSSION ETHICSETHICS PHILOSOPHICALPHILOSOPHICAL ACCEPTANCEACCEPTANCE

„ IsIs defineddefined outsideoutside thethe aa prioripriori criteriacriteria ofof aa goodgood life.life. ItIt isis foundfound inin thethe praxis,praxis, ratherrather thanthan inin thethe substance,substance, ofof discussion;discussion; i.e.i.e. inin thethe processprocess leadingleading toto consensus.consensus.

„ ““ValuesValues dodo notnot comecome simplysimply fromfrom thethe factfact thatthat theythey areare universallyuniversally shared.shared. InIn thethe approximatelyapproximately idealideal conditionsconditions neededneeded forfor aa rationalrational discussion,discussion, theythey mustmust bebe approvedapproved byby everyoneeveryone whowho maymay bebe concernedconcerned..”” ((HabermasHabermas))

„ Discussion,Discussion, aa communicationcommunication practice,practice, representsrepresents thethe onlyonly solutionsolution aptapt toto replacereplace moremore oror lessless violentviolent quarrelsquarrels ofof influenceinfluence betweenbetween thethe defendersdefenders ofof differentdifferent values.values.

JASP Quebec City, November 24, 2010 23 DISCOURSEDISCOURSE ETHICSETHICS PHILOSOPHICALPHILOSOPHICAL LEGITIMACYLEGITIMACY

„ CommonCommon sense:sense: aa formform ofof knowledgeknowledge basedbased onon techniques,techniques, processesprocesses andand rulesrules thatthat guaranteeguarantee anan ethicallyethically legitimatelegitimate discussion.discussion.

„ HereHere discoursediscourse refersrefers toto thethe procedureprocedure byby whichwhich ourour motivationsmotivations andand practicalpractical convictionsconvictions areare validatedvalidated throughthrough argument.argument.

„ LegitimacyLegitimacy isis anan ethicalethical procedureprocedure thatthat postulatespostulates thatthat inin ourour multimulti--moralmoral societies,societies, thethe onlyonly wayway toto constructconstruct fairfair sharedshared valuesvalues isis throughthrough arguedargued andand egalitarianegalitarian discussiondiscussion amongamong allall interestedinterested parties,parties, discussiondiscussion thatthat leadsleads toto aa consensus.consensus.

JASP Quebec City, November 24, 2010 24 LIMITSLIMITS OFOF THETHE DISCUSSIONDISCUSSION

„„ SpecifiesSpecifies neitherneither thethe sourcesource termsterms nornor thethe basicbasic vocabularyvocabulary ofof discoursediscourse ethicsethics

„„ DefinesDefines neitherneither thethe kindkind ofof participantsparticipants nornor theirtheir role:role: expertsexperts oror representativesrepresentatives ofof thethe publicpublic

JASP Quebec City, November 24, 2010 25 CONCLUSIONCONCLUSION

„ ImportanceImportance ofof discoursediscourse ethicsethics thatthat examinesexamines aa listlist ofof fundamentalfundamental principlesprinciples oror valuesvalues toto prepareprepare forfor actionaction „ AvoidAvoid dogmatismdogmatism inin thethe arbitrationarbitration betweenbetween principlesprinciples (e.g.(e.g. lettingletting autonomyautonomy oror eveneven justicejustice dictatedictate results)results) „ Fundamental:Fundamental: anan ethnoethno--ethicsethics thatthat definesdefines thethe valuesvalues thatthat willwill serveserve asas guidesguides forfor actionaction „ AA discoursediscourse ethicsethics thatthat avoidsavoids thethe abusesabuses ofof ethicalethical expertiseexpertise andand fostersfosters thethe accountabilityaccountability ofof eacheach andand everyevery publicpublic healthhealth professionalprofessional

JASP Quebec City, November 24, 2010 26