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A. Dawson, M. Verweij (2007)Ethics, prevention, and public health
C. Sunstein, Richard Thaler (2006)The Construction of Preference: Libertarian Paternalism Is Not an Oxymoron
A. Braunack-Mayer (2010)Teaching Ethics with ‘Cholera and Nothing More’
Public Health Ethics, 3
Victoria Doudenkova, J. Bélisle-Pipon, L. Ringuette, V. Ravitsky, B. Williams-Jones (2017)Ethics education in public health: where are we now and where are we going?
International Journal of Ethics Education, 2
M. Selgelid, D. Barrett, Leonard Ortmann, A. Dawson, A. Reis, G. Bolan (2016)Public health ethics : cases spanning the globe
J. Marks (2017)Caveat Partner: Sharing Responsibility for Health With the Food Industry.
American journal of public health, 107 3
K. Grill (2009)Liberalism, Altruism and Group Consent
Public Health Ethics, 2
James Wilson (2011)Why It's Time to Stop Worrying About Paternalism in Health Policy
Public Health Ethics, 4
T. Tempels, M. Verweij, V. Blok (2017)Big Food's Ambivalence: Seeking Profit and Responsibility for Health
American Journal of Public Health, 107
A. Dawson, M. Verweij (2017)No Smoke Without Fire: Harm Reduction, E-Cigarettes and the Smoking Endgame
Public Health, 10
Sarah Conly (2013)Coercive Paternalism in Health Care: Against Freedom of Choice
Public Health Ethics, 6
T. Nys (2008)Paternalism in Public Health Care
Public Health Ethics, 1
B. Jennings, Jeffrey Khan, A. Mastroianni, L. Parker, H. Alvarez, R. Bayer, R. Bernheim, R. Bonnie, M. Garland, L. Gostin, E. Heitman, P. Marshall, Laura McKieran, P. Nieburg, K. Shrader-Frechette, J. Stull, James Thomas, Stephen Thomas (2003)Ethics and Public Health : Model Curriculum
Teaching Ethics, 13
Public Health Ethics first appeared in April 2008, so with this issue, we celebrate 10 years of publication. The interest in public health ethics as a subfield of bioethics, already beginning to grow before the birth of the journal, has continued to expand steadily throughout this period. The success of Public Health Ethics over these 10 years is a reason for celebration. However, it is good to put this in perspective, in that a significant part of the interest is due to the continuing global need for public health action to address population-level health problems, the ongoing lack of public health infrastructures and poor environmental health in many places in the world, the growing health inequalities between rich and poor and growing health risks due to climate change, population movement, ageing, antimicrobial resistance and overconsumption. In this brief anniversary editorial, we aim to comment on several developments we have seen over the years, set out some expectations for the future and propose some issues that we think stand in need of more systematic analysis. We made a simple analysis of the prevalence of themes, topics and concepts addressed in papers published in the journal and those available online via the advanced search option of the journal’s website (Table 1). Our approach was unsystematic in the sense that we only searched for a number of terms that occurred to us as relevant. As simple as the analysis is, it does serve as a basis for some reflections on how public health and public health ethics have evolved in the previous decade. Table 1. How often do specific terms occur in abstract or title of the 384 papers available online in Public Health Ethics, 1 January 2018? Values, concepts, theories Health interventions/areas Privacy 10 Vaccine/vaccination 22 Autonomy 30 Quarantine 2 Informed consent 17 Surveillance 4 Justice 51 Health promotion 10 Inequality 34 Nudges 2 Human rights 9 Priority setting 6 Reciprocity 6 Screening 10 Solidarity 15 Mental health 8 Stewardship 4 Reproductive health 0 Paternalism 18 Occupational health 1 Egalitarian(ism) 7 Environmental health 1 Republican(ism) 7 Global health 14 Liberal(ism) 18 Humanitarian care 12 Utilitarian(ism) 5 Law 17 Capability approach 2 Research ethics 12 Feminist (ethics) 1 Diseases and conditions Health determinants Ebola 4 Alcohol 7 Influenza 7 Smoking 14 HIV 15 Sport 1 Malaria 2 Safety 6 Tuberculosis 3 Food 15 Cancer 6 Genetic 6 Cardiovascular disease 2 Social determinants 10 Obesity 10 Family planning 1 War 4 Poverty 1 Climate change 3 Animals 3 Companies 5 Antimicrobial resistance 5 Pandemic 12 Values, concepts, theories Health interventions/areas Privacy 10 Vaccine/vaccination 22 Autonomy 30 Quarantine 2 Informed consent 17 Surveillance 4 Justice 51 Health promotion 10 Inequality 34 Nudges 2 Human rights 9 Priority setting 6 Reciprocity 6 Screening 10 Solidarity 15 Mental health 8 Stewardship 4 Reproductive health 0 Paternalism 18 Occupational health 1 Egalitarian(ism) 7 Environmental health 1 Republican(ism) 7 Global health 14 Liberal(ism) 18 Humanitarian care 12 Utilitarian(ism) 5 Law 17 Capability approach 2 Research ethics 12 Feminist (ethics) 1 Diseases and conditions Health determinants Ebola 4 Alcohol 7 Influenza 7 Smoking 14 HIV 15 Sport 1 Malaria 2 Safety 6 Tuberculosis 3 Food 15 Cancer 6 Genetic 6 Cardiovascular disease 2 Social determinants 10 Obesity 10 Family planning 1 War 4 Poverty 1 Climate change 3 Animals 3 Companies 5 Antimicrobial resistance 5 Pandemic 12 Beyond Utilitarianism First of all, it is remarkable that, as shown in the table, the terms ‘utilitarian’ and ‘utilitarianism’ do not occur frequently in titles and abstracts in Public Health Ethics. This is in stark contrast with an assumption that we still think many people hold, namely, that public health and public health ethics have a strong utilitarian tendency. Instead, liberalism, republicanism and egalitarianism, but also terms like justice, inequality and human rights, are used much more often. Obviously, taking a population perspective on health problems involves aggregative as well as distributive dimensions (Verweij and Dawson, 2007). However, even if a consequentialist perspective was to be most prominent in public health ethics, it may well be pluralist and hence much richer than an all-too-simple focus on maximizing utility. In any case, whatever one thinks of utilitarianism as a valid approach to normative theory, there is little reason to see it as the dominant ethical approach within public health ethics. Rehabilitating Paternalism It is no surprise that ‘paternalism’ features as a prominent term in the titles and abstracts of articles in Public Health Ethics. Our impression is that this concept has lost much of the negative connotation it used to have in the past, and this shift has accelerated in the past decade. Some key articles in public health ethics may have contributed to this development, all offering a more nuanced or critical picture of how paternalism can be understood and evaluated (Nys, 2008; Grill, 2009; Wilson, 2011; Conly, 2013). There are however many other explanations for the rehabilitation of paternalism. One is the by now broad acceptance of the limitations of our rationality in day-to-day behaviour, a central topic in behavioural economics, and which has given rise to Sunstein and Thaler’s (2003) stance that even libertarians can embrace (a certain form of) paternalism. Another factor that has contributed to a more positive view of paternalism in public health is our growing insight in the social determinants of health. Even if a large part of inequalities in health can be related to the lifestyle choices of individuals, it is clear that there are underlying societal factors that shape how different patterns of health behaviour emerge in different socio-economic groups. Facts about limits to human rationality and about the social determinants of health are amongst the reasons why we should move away from an obsession about paternalism. Public health policy and practice is often motivated by an intention to address such factors, not just to intentionally ‘override’ the freedom of individuals. Infectious Diseases A third, equally unsurprising observation is the prominent place given to infectious diseases and public health interventions like vaccination, quarantine and surveillance. Of all health conditions that we looked at, HIV is mentioned most often. Arguably, the global HIV/AIDS epidemic has been one of the main drivers of the development of public health ethics as a new field of studies. The relatively high numbers of papers that deal with HIV/AIDS reflect how this infectious disease and the potential ways to reduce risks of infection are still central in global public health discussions. It is interesting to note how cardiovascular diseases—responsible for more than 30% of all mortality worldwide—are, as a disease-type, hardly mentioned. This is not to say that prevention of stroke and heart disease raises little attention: after all, major risk factors for such diseases like smoking and the consumption of unhealthy food are frequent topics. Towards Tobacco Endgames? Smoking and tobacco policies have been a significant and ongoing theme in the journal as well as in public health practice. Smoking is still one of the major killers—with a death toll of 7 million each year (WHO). Almost 1 million tobacco-caused deaths are caused by exposure to other people’s smoke. In the past 10–15 years, significant advances have been made in building strong preventive smoking policies. Tobacco policies have become increasingly restrictive in many countries, and it even has become common to talk about creating smoke-free generations and a tobacco ‘end-game’. The idea that there is no moral basis for allowing the sale of cigarettes is increasingly accepted in the Western world (Verweij, 2017). At the same time, it is clear that tobacco companies seek new ways to expand and sell their products, targeting low- and middle-income countries where more than 80 percent of all smokers live, or via new products such as e-cigarettes (Dawson and Verweij, 2017). New Roles for Private Companies? Private companies are mentioned a few times in abstracts, but much more often in full text articles (in 107 of the 384 articles). Relevant business areas include pharmaceutical and other medical companies, the tobacco industry, food and beverage companies and restaurants. Mostly their role is criticized, or otherwise put forward as a potential risk to public health. For the tobacco industry, this will be obvious given that almost all tobacco products are harmful and addictive. Pharmaceutical companies have specifically featured in ethical debates about unequal access to essential medicines. The food and beverage industry is seen as a major factor in health problems like obesity and alcohol abuse. Indeed, for good reasons public health ethics often focuses on the responsibility of governments to enforce health policies and curtail potential harmful effects of market behaviour. An interesting area for future ethical reflection, however, would also be the opportunities for, and indeed social responsibilities of, corporations to promote public health. For the tobacco industry, arguably the only way to wholeheartedly contribute to public health is to discontinue their business altogether. Yet food companies, retailers and restaurants might significantly contribute to a health-promoting environment, through innovation in products (i.e. reducing sugar and salt content), nudging consumers, promoting increased vegetable consumption, giving less priority to meat, etc. (Tempels et al., 2017). Some public health scholars have little confidence in the potential role of corporate social responsibility in the food industry (Marks, 2017) and primarily call on governments to impose laws that require companies to refrain from activities that may undermine public health. Yet if we see public health as a genuinely collective and societal activity, it makes little sense to focus only on the obligations of government and individual citizens, as this leaves out many potentially influential collective actors, including schools, public and community institutions, NGOs, etc. At least in a world dominated by a global-free market, we should attempt to ensure that such companies are aware of, and take seriously, their responsibilities to contribute to the health of the population. Crossing the Boundaries between Medical Ethics and Public Health Since the first issue of Public Health Ethics, we have sought to emphasize how this field of studies is different from clinical bioethics, both in terms of what types of facts are particularly morally relevant, and in terms of the relative weight of values like health, autonomy, community, equity and solidarity. It makes sense, however, to see the many areas where both fields of studies overlap. One such area is antibiotic resistance. Not only can emerging antibiotic resistance be seen to raise ethical questions of justice and priority setting (how to distribute antibiotic effectiveness over generations?) but there are also important questions about how control measures are set up in healthcare settings to prevent transmission of resistant pathogens and how they might endanger the quality of care for patients who are carriers of such pathogens. Pitting a public health against a clinical approach is not very helpful for developing responsible and comprehensive policies in this context. Dealing with scarce resources in healthcare, and the questions of equitable access to such resources, is another clear area of overlap between public health and medical ethics. In the next few years we expect a renewed debate on the possible limits to publicly funded healthcare. Due to the success of welfare programmes, improved nutrition, housing and access to healthcare, populations in most parts of the world are living increasingly long lives. This, along with the increasing costs of many novel medicines such as those targeting cancer and metabolic diseases, will result in greater pressure on health budgets. Such debates potentially threaten to undermine solidarity in currently strong health systems (such as those in many high-income countries) or imperil the move towards universal health coverage across low- and middle-income countries. Thinking about fair models of pharmaceutical innovation, and rethinking what we should see as essential healthcare, will be central themes for both medical ethics and public health ethics in the next decade. Strengthening Interest in Public Health Ethics Education A final observation concerns what is absent rather than visible in the table. In the past 10 years, almost no contributions specifically dealt with teaching public health ethics. An exception is Annette Braunack’s short reflection on how one of the case discussions could be used for teaching purposes (Braunack-Mayer, 2010). Public health ethics is increasingly seen as central to education in schools of public health (Doudenkova et al., 2017). Important influences on these developments have been open-access text books, curricula and case discussions, such as the Model Curriculum produced for the American Association of Schools of Public Health (Jennings et al., 2003) and the casebooks produced by the Canadian Institutes of Health Research’s Institute of Population and Public Health (2012) and Public Health Ethics: Cases spanning the globe (Barrett et al., 2016), led by the US Centers for Disease Control and Prevention. More systematic research into teaching practices and the effectiveness of method in strengthening ethical sensitivity and skills would be highly desirable. As another way to contribute to skills in ethical deliberation and decision-making among professionals, Public Health Ethics also welcomes contributions to our section on ‘case studies’ that focus on practical dilemmas in public health work ‘on the ground’. Public Health Ethics—Still Not as Global as One Would Hope Finally, let us take a look at the authors who have published work in Public Health Ethics so far (Table 2). It will be no surprise that by far the largest numbers of papers were submitted by authors from ‘Western’ countries: more than 90 per cent of the papers that have been accepted for publication before 1 January 2018 are from Europe, the USA, Canada, Australia or New Zealand. The number of contributions from Africa, Asia and South America is still very low. This is a significant problem, as many of the ethical issues in public health that are discussed in the journal are prominent in low- and middle-income countries, and it is essential that philosophers, bioethicists and health professionals from these areas participate in scholarly debates about such issues. As an editorial team we try to make it more feasible from authors from other parts of the world to publish papers in Public Health Ethics. For example, we encourage individual scholars to write and submit manuscripts, and we also offer extra support and feedback on top of reviewers’ comments. In the coming years we intend to devote case discussions specifically to problems in low-income contexts, and to be more active in inviting scholars from Africa and Latin America to publish in Public Health Ethics. We are particularly interested in receiving work from colleagues living and working in countries where they can draw upon non-Western ethical traditions and teach us all how we can learn from the cultural riches that are invisible to many of us. In particular, we encourage the discussion of different indigenous ways of thinking and valuing and their application to issues in public health. Table 2. Nationality of submitting author of papers accepted before 1 January 2018 Europe 154 North America (the USA and Canada) 135 Australia and New Zealand 38 Asia (including Asia Minor) 17 Africa 6 South and Central America 3 Europe 154 North America (the USA and Canada) 135 Australia and New Zealand 38 Asia (including Asia Minor) 17 Africa 6 South and Central America 3 Thanks to Reviewers Public Health Ethics has flourished in its first decade, and there is little reason to expect this will change in the years to come. A key factor in this success is the work of our editorial board and peer reviewers. As an editorial team we are fully aware how doing the work of peer review is demanding and that there are few visible rewards. Our field of study depends on the collective efforts of academics and practitioners being willing to read and evaluate manuscripts and to offer feedback that helps colleagues to improve and sharpen their analyses. We are extremely grateful for all the work that our reviewers and editorial board have done, anonymously, for Public Health Ethics. References Barrett D. H., Ortmann L. W., Dawson A. J., Saenz C., Reis A., Bolan G. ( 2016) Public Health Ethics: Cases Spanning the Globe . Springer. Available from: https://doi.org/10.1007/978-3-319-23847-0. Google Scholar CrossRef Search ADS Braunack-Mayer A. ( 2010). Teaching Ethics with ‘Cholera and Nothing More’. Public Health Ethics , 3, 78– 79. Available from: https://doi.org/10.1093/phe/phq007. Google Scholar CrossRef Search ADS Canadian Institutes of Health Research’s Institute of Population and Public Health. ( 2012). Population and Public Health Ethics: Cases from Research, Policy, and Practice . Toronto: Joint Centre for Bioethics, University of Toronto. Available from: http://jcb.utoronto.ca/publications/documents/Population-and-Public-Health-Ethics-Casebook-ENGLISH.pdf [accessed 12 January 2018]. Conly S. ( 2013). Coercive Paternalism in Health Care: Against Freedom of Choice. Public Health Ethics , 6, 241– 245. Available from: https://doi.org/10.1093/phe/pht025. Google Scholar CrossRef Search ADS Dawson A., Verweij M. F. ( 2017). No Smoke without Fire: Harm Reduction, E-Cigarettes and the Smoking Endgame. Public Health Ethics , 10, 1– 4. Available from: https://doi.org/10.1093/phe/phx003. Doudenkova V., Bélisle-Pipon J. C., Ringuette L., Ravitsky V., Williams-Jones B. ( 2017). Ethics Education in Public Health: Where are We Now and Where are We Going? International Journal of Ethics Education , 2, 109. Available from: https://doi.org/10.1007/s40889-017-0038-y. Google Scholar CrossRef Search ADS Grill K. ( 2009). Liberalism, Altruism and Group Consent. Public Health Ethics , 2, 146– 157. Available from: https://doi.org/10.1093/phe/php014. Google Scholar CrossRef Search ADS Jennings B., Kahn J., Mastroianni A., Parker L. S. ( 2003) Ethics and Public Health: Model Curriculum . Washington: Health Resources and Services Administration, Association of Schools of Public Health and Hastings Centre. Available from: http://hdl.handle.net/10822/556779. Marks J. H. ( 2017). Caveat Partner: Sharing Responsibility for Health with the Food Industry. American Journal of Public Health , 107, 360– 361. Available from: https://doi.org/10.2105/AJPH.2016.303646. Google Scholar CrossRef Search ADS PubMed Nys T. R. V. ( 2008). Paternalism in Public Health Care. Public Health Ethics , 1, 64– 72. Available from: https://doi.org/10.1093/phe/phn002. Google Scholar CrossRef Search ADS Sunstein C., Thaler R. ( 2003). Libertarian Paternalism is Not an Oxymoron. The University of Chicago Law Review , 70, 1159– 1202. Available from: https://doi.org/10.2307/1600573. Google Scholar CrossRef Search ADS Tempels T., Verweij M. F., Blok V. ( 2017). Big Food’s Ambivalence: Seeking Profit and Responsibility for Health. American Journal of Public Health , 107, 402– 406. Available from: https://doi.org/10.2105/AJPH.2016.303601. Google Scholar CrossRef Search ADS PubMed Verweij M., Dawson A. ( 2007). The Meaning of ‘Public’ in Public Health. In Dawson A., Verweij M. (eds), Ethics, Prevention, and Public Health . New York, NY: Oxford University Press, pp. 13– 29. Verweij M. F. ( 2017). Anti-Rookbeleid is Morele Taak Van Overheid. Nederlands Tijdschrift Voor Geneeskunde , 161, D1351. Google Scholar PubMed Wilson J. ( 2011). Why it's Time to Stop Worrying about Paternalism in Health Policy. Public Health Ethics , 4, 269– 279. Available from: https://doi.org/10.1093/phe/phr028. Google Scholar CrossRef Search ADS © The Author(s) 2018. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
Public Health Ethics – Oxford University Press
Published: Apr 1, 2018
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