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Public health: ethical issues Published by Nuffield Council on Bioethics 28 Bedford Square London WC1B 3JS Telephone: 020 7681 9619 Fax: 020 7637 1712 Email: [email protected] Website: http://www.nuffieldbioethics.org ISBN 978-1-904384-17-5 November 2007 To order a printed copy please contact the Nuffield Council on Bioethics or visit the website. European countries (EU and non EU): £10 per report (where sold) Countries outside Europe: £15 per report (where sold) Developing countries (single copies): Free CD-ROMs: Free © Nuffield Council on Bioethics 2007 All rights reserved. Apart from fair dealing for the purpose of private study, research, criticism or review, no part of the publication may be produced, stored in a retrieval system or transmitted in any form, or by any means, without prior permission of the copyright owners. Web references throughout this report were accessed July/August 2007. Produced by: Cambridge Publishers Ltd 275 Newmarket Road Cambridge CB5 8JE www.cpl.biz Printed in the UK Public health: ethical issues Nuffield Council on Bioethics Professor Sir Bob Hepple QC FBA (Chairman) Professor Peter Smith CBE FMedSci (Deputy Chairman) Professor Roger Brownsword Professor Sir Kenneth Calman KCB FRSE Professor Sian Harding FAHA Professor Peter Harper The Rt Revd Lord Harries of Pentregarth DD FKC FRSL FMedSci Professor Ray Hill FMedSci Professor Søren Holm Mr Anatole Kaletsky Dr Rhona Knight FRCGP Lord Krebs Kt FRS FMedSci* Professor Peter Lipton FMedSci Professor Alison Murdoch FRCOG Dr Bronwyn Parry Professor Hugh Perry FMedSci Lord Plant of Highfield Professor Nikolas Rose * co-opted member of the Council while chairing the Working Party on Public health: ethical issues Secretariat Hugh Whittall (Director) Professor Sandy Thomas (Director until November 2006) Dr Catherine Moody (until March 2007) Harald Schmidt Katharine Wright Carol Perkins Catherine Joynson Caroline Rogers Julia Trusler Clare Stephens (until March 2006) Audrey Kelly-Gardner Kate Harvey 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 iii Foreword Whose job is it to ensure that we lead a healthy life? Who should help us not to eat or drink too much, to take exercise, and to protect our children and ourselves against disease? Is it entirely up to us as individuals to choose how to lead our lives, or does the state also have a role to play? Two typical, and contradictory, responses are “We don’t want the nanny state interfering with our lives” and “The Government should do more to curb drunkenness amongst young people”. This Report presents an ethical framework that aims to help answer the question of when and how the state should act. The term ‘public health’ refers to the efforts of society as a whole to improve the health of the population and prevent illness. The emphasis of public health policy on prevention rather than treatment of the sick, on the population as a whole rather than the individual, and the importance of collective effort, poses a particular set of ethical problems. In traditional bioethics, much emphasis is placed on the freedom of the individual, in terms of consent, treatment and information. Whilst these freedoms remain in ethical considerations of public health, they are woven into a complex fabric, in which many different players have roles and responsibilities. People are much healthier today than they were 150 years ago. Since the turn of the 20th Century, life expectancy has increased by nearly 70%, equivalent to 16 hours per day. Much of this change is a result of what might be seen as quite interventionist public health policies such as provision of clean water, sanitation and mandatory vaccination, as well as protection of workers and children through specific legislation. In all of this the state has played a central role in improving people’s health. People’s perception of acceptable risk has changed as we have become healthier. In the 1930s there were about 2,000 deaths per year from bovine tuberculosis, contracted largely through raw milk. Yet parliament decided that the risks did not warrant legislation to prevent these deaths by pasteurising milk. When the Pasteurisation Bill finally came before parliament in 1949, Dr Edith Summerskill said: “Pasteurisation has been prevented by ignorance, prejudice and selfishness.” Perhaps something similar will be said in the future about the unsubstantiated MMR-autism scare, which led to the refusal of many parents to vaccinate their children against measles, mumps and rubella. In Chapter 3 we discuss the acceptability of risk and the nature of evidence, as well as the responsibility of the media, all too often not fulfilled, in accurate rather than biased and sensationalist reporting. It takes only a moment’s thought to recognise that many of the ‘choices’ that individuals make about their lifestyle are heavily constrained as a result of policies established by central and local government, by various industries as well as by various kinds of inequality in society. People’s choice about what to eat, whether or not they allow their children to walk to school, or the kinds of products that are marketed to them, are often, in reality, limited. This means that the notion of individual choice determining health is too simplistic. Instead, we develop what we call the ‘stewardship model’ of the role of the state in relation to public health. This model recognises that the state should not coerce people or restrict their freedoms unnecessarily, but also that the state has a responsibility to provide the conditions under which people can lead healthy lives if they wish. The stewardship state, in addition to protecting its citizens from harm caused by others, sees itself as having a particular responsibility for protecting the health of vulnerable groups such as children, and in closing the gap between the most and least healthy in society (as overall life expectancy has increased, the gap has not closed). Some may find our ethical framework strays too far away from the freedoms of the individual and toward the value of the community as a whole. But our conclusion is that any state that seriously aims to promote and implement public health policies has to accept a stewardship role. We also v note that ‘doing nothing’ is an active decision by the state that will have an impact on people’s ability to lead a healthy life. We describe the different kinds of intervention that the state may use to promote public health, on what we term the ‘intervention ladder’, from the least to the most coercive or intrusive measures. The further up the ladder the state climbs, the stronger the justification has to be. We consider four case studies within our stewardship framework: infectious disease, obesity, smoking and alcohol (as a compare and contrast case) and fluoridation of water. Each case highlights different aspects of the stewardship state. Our model does not lead to a set of rules for the stewardship state, but rather a set of guidelines and signposts for the state as well as others involved in public health policy. We have highlighted these in the recommendations and conclusions throughout the report. I would like to thank all those involved in the preparation of this Report: the members of the Working Party, the Council, the excellent secretariat, in particular Harald Schmidt, Julia Trusler and Caroline Rogers, those who responded to our consultation, and those who came to our fact- finding meetings to brief us and debate their views. Lord Krebs Kt FRS FMedSci Chair of the Working Party vi Acknowledgements The Council would like to thank the members of the Working Party for their expertise and contributions to this Report. Also greatly appreciated were the peer review comments from the experts who reviewed an earlier version of this Report (see Appendix 1), and comments from those who have attended fact-finding meetings (see Appendix 1) and responded to our consultation (see Appendix 2). Members are also very grateful to those who provided advice on specific parts of the Report, including Professor Alex Capron, Dr Andreas Reis, Dr Angus Nicoll, Dr Barry Evans, Dr Bryony Butland, Dr Elaine Gadd, Dr Ben Goldacre, colleagues at the Faculty of Public Health of the Royal Colleges of Physicians of the United Kingdom, Hermine Kelly-Hall, John Graham, Professor Mark Johnson, Professor Ron Bayer, Sarah Clark, Stephen Peckham and Professor Trevor Sheldon. Finally, we thank Anais Rameau, an intern with the Council, for her valuable work. vii Members of the Working Group Lord Krebs Kt FRS FMedSci (Chair) Principal, Jesus College, University of Oxford Dr Raghib Ali Clinical Lecturer, Department of Clinical Pharmacology, Green College, University of Oxford Professor Tom Baldwin Professor of Philosophy, Department of Philosophy, University of York Professor Roger Brownsword Professor of Law, Centre for Medical Law and Ethics,
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