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Public Health: Ethical Issues CONSULTATION PAPER

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Public Health: Ethical Issues CONSULTATION PAPER Public health: ethical issues CONSULTATION PAPER Deadline for responses: 15 September 2006 Nuffield Council on Bioethics Professor Sir Bob Hepple QC, FBA (Chairman) Professor Peter Smith CBE (Deputy Chairman) Professor Margot Brazier OBE* Professor Roger Brownsword Professor Sir Kenneth Calman KCB FRCS DL FRSE Professor Peter Harper Rt Reverend Richard Harries DD FKC FRSL Professor Sir John Krebs FRS** Professor Peter Lipton Lord Plant of Highfield Mr Anatole Kaletsky Dr Rhona Knight Professor Hugh Perry Professor Dame Marilyn Strathern DBE FBA Dr Alan Williamson FRSE * co-opted member of the Council while chairing the Working Party on critical care decisions in fetal and neonatal medicine ** co-opted member of the Council while chairing the Working Party on Public health: ethical issues Secretariat Professor Sandy Thomas (Director) Dr Catherine Moody Mr Harald Schmidt Ms Catherine Joynson Ms Julia Trusler Ms Caroline Rogers Ms Carol Perkins Ms Audrey Kelly-Gardner The terms of reference of the Council are: 1 to identify and define ethical questions raised by recent advances in biological and medical research in order to respond to, and to anticipate, public concern; 2 to make arrangements for examining and reporting on such questions with a view to promoting public understanding and discussion; this may lead, where needed, to the formulation of new guidelines by the appropriate regulatory or other body; 3 in the light of the outcome of its work, to publish reports; and to make representations, as the Council may judge appropriate. The Nuffield Council on Bioethics is funded jointly by the Medical Research Council, the Nuffield Foundation and the Wellcome Trust 2 Public health: ethical issues Consultation paper Contents Members of the Working Party on Public health: ethical issues ........................ 5 Terms of reference of the Working Party ...................................................... 6 Part A 1 Introduction............................................................................................ 7 2 List of questions ..................................................................................... 9 Part B..................................................................................................... 13 3 Background and policy context ............................................................... 13 4 Case studies......................................................................................... 17 4.1 Case Study - Prevention and control of infectious diseases ..................17 4.2 Case Study - Obesity.......................................................................22 4.3 Case Study - Smoking .....................................................................26 4.4 Case Study - Alcohol.......................................................................29 4.5 Case Study - Supplementation of food and water................................32 5 Ethical issues........................................................................................ 36 Further sources of information................................................................... 41 Responding to the consultation.................................................................. 42 Respondent’s form................................................................................... 43 3 4 Members of the Working Party on Public health: ethical issues Professor Sir John Krebs FRS (Chair) Principal, Jesus College, Oxford Dr Raghib Ali Clinical Lecturer, Department of Clinical Pharmacology, Green College, University of Oxford Professor Tom Baldwin Department of Philosophy, University of York, Member of the Council (up to January 2006) Professor Roger Brownsword Professor of Law, King’s College London, Member of the Council Professor Sir Kenneth Calman KCB FRCS DL FRSE Vice-Chancellor and Warden, University of Durham, Member of the Council Professor Christine Godfrey Professor of Health Economics, Centre for Health Economics and Department of Health Sciences and Clinical Evaluation, University of York Professor Trisha Greenhalgh OBE Professor of Primary Health Care, Department of Primary Care and Population Sciences (PCPS), University College London Professor Anne Johnson FMedSci Professor of Infectious Disease Epidemiology and Head of Department, Department of Primary Care and Population Sciences (PCPS), University College London Professor Sally Macintyre OBE FRSE Director, Medical Research Council Social and Public Health Sciences Unit, University of Glasgow Professor Jonathan Montgomery Professor of Health Care Law, University of Southampton School of Law Julia Unwin OBE Deputy Chair, Food Standards Agency, and Senior Associate, King’s Fund 5 Terms of reference of the Working Party on: Public health: ethical issues 1 To identify and consider ethical, legal and social issues arising when designing measures to improve public health. 2 To consider, by means of case studies: a) the variety of aims for such measures, such as informing individual choices and protecting the wider community, and their relative priorities; b) the role of autonomy, consent and solidarity; c) issues raised by decisions about, and perceptions of, risk; d) criteria for the allocation of resources in specific areas of public health; e) the special situation of children and those who are poor or socially excluded. 3 To examine the implications of the above for the development of frameworks for policy making in public health. 6 Part A 1 Introduction Health matters to everyone, to ourselves, our families, our communities, and the state. There are many definitions of the term ‘public health’. One of these describes the promotion of public health as ”what we, as a society, collectively do to assure the conditions for people to be healthy”.1 In common with other definitions, it raises a number of questions. These include: What are the responsibilities of governments? Should they aim to achieve certain states of health in the population, or merely to provide circumstances that allow people to make informed decisions? If the role of the state is to achieve certain states of health, is the primary responsibility to prevent harm, or should states also promote positive conceptions of health? Do governments bear responsibility for inequalities in the health of particular groups of citizens? Or are poorer states of health in some ethnic or socio-economic groups merely a matter of personal responsibility? What are the responsibilities of individuals? Should people be completely free from interference by the state in choosing how they live their life regardless of the implications for their health? If people deliberately or negligently behave in ways that harm their health, should they be entitled to treatment provided through publicly funded healthcare systems such as the NHS? Should health risks arising from different conditions and lifestyle choices, for example obesity, smoking, sunbathing, rock-climbing or cycling in big cities all be evaluated in the same way? What are the responsibilities of other parties, such as communities and industries? Increasing emphasis on individual choice and responsibility focuses attention on the circumstances in which people make choices, and the responsibility of those who influence how people make choices. For example, if nearly half of all ready-made meals contain high levels of salt2 are people who choose to eat them responsible for the high blood pressure that may result? Or do producers of ready meals also bear some 1 Institute of Medicine (1988) The Future of the Public Health (Washington, USA: The National Academies Press). According to the Faculty of Public Health of the Royal Colleges of Physicians of the United Kingdom the term ‘public health’ refers to: “The science and art of preventing disease, prolonging life and promoting health through organised efforts of society”, see Royal Colleges of Physicians of the United Kingdom What is public health?, available at: www.fphm.org.uk/about_faculty/what_public_health/default.asp, accessed on: 19 Apr 2006. 2 Food Standards Agency (2003) Ready meals salt levels revealed, available at: www.food.gov.uk/news/pressreleases/2003/jun/readysaltpress, accessed on: 5 Apr 2006. 7 responsibility? Additionally, what are the obligations of the tobacco and alcohol industries in warning consumers of the risks of consumption? Value systems and practices shared by family members and the wider community determine to a considerable degree what counts as eating or drinking too much, or exercising too little. Can or should the communities in which these values are established play a role in promoting public health? In January 2006, the Nuffield Council on Bioethics established a Working Party to consider the complex issues that arise when designing and introducing measures to improve public health. The Working Party will publish a Report in 2007, formulating advice that is primarily relevant to UK policy and practice. The Report will summarise the discussions of the Working Party, which will also be informed by facts, arguments and opinions from a wider consultation with external experts.3 This document forms an important part of the consultation process, and the Council and the Working Party would welcome your comments on ethical issues that are raised by measures to improve public health. We begin in Part A by providing a list of questions that relate the more general issues introduced above to five specific areas of public health: infectious diseases, obesity, smoking, alcohol, and
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