Chapter 14 Decision-making

Decision-Making: Policies and Ethics in Health Care and Public Health

After reading this chapter, you will be able to:

Public Policies

As early as the 19th century, people recognized the link between politics and health. More than a century ago, Rudolph Virchow wrote that “medicine is a social science, and politics nothing but medicine on a grand scale.”1 One hundred years later, Michael Rachlis noted that “patterns of health and illness are reflections of our values, culture and institutions”.2 The reasons for these statements can be found in Chapter 2, where discussion of the determinants of health shows that the factors that influence health are linked to the economy, the political system, and to culture as a whole.

Rudolph Virchow

Dr. Rudolph Virchow (1821–1902), a Prussian, was Chair of Pathological Anatomy at the University of Berlin. He designed a sewerage system for the city of Berlin. During the Franco-German war, Dr. Virchow led the first hospital train to the front lines where he attended to injured soldiers. He is known as one of the fathers of modern pathology and one of the founders of social medicine. A number of entities are named after him, including Virchow’s angle, Virchow’s cell, Virchow’s disease, Virchow’s node, and Virchow’s triad.

Politics and policies

Policy refers to a course or principle of action adopted or proposed by a government, a political party, organisation, individual, or interest group.3

Politics refers to the art and science of government or to activities concerned with the acquisition and exercise of authority or power.3 Politics has also been defined as the activities that determine of who gets what, when, and how.4 The term encompasses more than the party political systems of national, provincial, and municipal government; it also refers to the struggle for power within any kind of organization, such as office politics, hospital politics, etc. It also describes the debates, battles and negotiations that lead to policies being chosen and implemented.

HEALTH POLICY matters can be classified into four major groups according to the level at which they affect the system:5, 6

  • Systemic matters concern the main features that shape the health system overall, such as the nature of public institutions involved in health care, the public/private mix, and the relationship between health and other sectors. An example would be, “who should pay for health care: the government or the person who uses it?”
  • Programmatic matters concern the priorities for health care, the actual nature of health care programmes, and the way in which resources should be allocated. An example would be, “what types of services should developed and funded?”
  • Organizational matters concern the way in which resources can be used productively and the ways to ensure a high quality service. An example would be, “how should we organize primary care centres and deploy interprofessional care teams?”
  • Instrumental matters concern the management of the various instruments of good organization, such as the human resource development and information systems. An example would be, “how can we best move to a unified system of electronic health records?”

At the same time, health policy issues can be classified by their likelihood of generating conflict among interest groups:

  • Highly political issues are those likely to elicit a strong response from the public, physicians, nurses, or other stakeholders. Reductions of service are generally in this category. In Canada, discussions surrounding the central tenets of the Canada Health Act nearly always fall in this category, especially those surrounding the private and public payment for health services.
  • Low political issues are those unlikely to elicit a great deal of response. Choosing to purchase rather than to lease laboratory equipment might fall into this category.

Health Policy, and Healthy Public Policy

HEALTH POLICY dictates who should do what to whom, when they should do it, what resources are available for doing, where they should do it, and who should pay for it. Health policy includes such things as the regulation and licensure of health care providers, the number of hospital beds in a community, arrangements for the insurance and payment of health services, the mix of public and private services, the variety, type and quality of services available in the community, and other issues such as access and cost of health services (see Chapter 12).

Health policies change according to health problems and in response to advances in technology and knowledge. Policy change is also influenced by political interests that can either obstruct or facilitate evidence-based policy proposals. Health policies are formed in a number of domains within the health care system. Some of these domains are shown in Table 14.1.

Table 14.1: Different domains of health policy decision-making

Policy domain Type of question Themes
Public policy Do we fund transplants? Issues and priorities
Administrative policy Where do we locate transplant services? Service delivery problems
Clinical policy Who should receive transplants? Intervention possibilities.

HEALTHY PUBLIC POLICY concerns the policies of other sectors (such as education or transportation), which affect health through their impact on the social determinants of health. For example, transportation policies influence the use of ACTIVE TRANSPORT; school curriculum design influences the amount of time devoted to physical activity and the inclusion of health topics; city zoning regulations affect the likelihood that emissions from industrial complexes endanger the health of surrounding populations. Similarly, policies that affect social inequity, social exclusion and access to education can affect health.7 In other words, improvements in health policy alone cannot achieve health; healthy public policies are also required. Healthy public policies are driven by broad social goals that evolve over time, as outlined in Table 14.2.

Table 14.2: Healthy public policy shifts in Canada8

Policy goals Basis Actions
Public health measures
(19th century)		 Observation of the role of contamination in producing disease Water management systems, food inspection, quarantine regulations
Universal health care coverage
(mid 20th century)		 Observation of the effects of the 1930s depression in Canada coupled with the belief that disease can be cured Medical services focussing on individual and the body
Health promotion
(late 20th century)		 Observation of the role of the social environment in producing health Funding of health promotion professionals and initiatives focussing on the social environment
Reduction of inequalities

(not yet achieved)

 Mid 20th century studies showing health gradient across socio-economic groups Quebec’s antipoverty law. Problem of “health imperialism” (health seen as pre-empting other public goals). This depends on other sectors (e.g. education) understanding their impact on health in order for change to occur.

Canadian health policy milestones

For examples of important milestones in Canadian healthy public policy, check out the Canadian Public Health Association’s ‘12 Great Public Health Achievements’ of the last 100 years.

Assessing the health impacts of public policies is a developing field in public health. It aims to produce evidence on the effects of a variety of polices such as the fluoridation of drinking water, transportation or urban planning policies.

How economic crises affect medicine

Towards the end of 2008, over-inflated national economies began to collapse leading to a world-wide severe recession which lasted several years. A student-run forum in Queen’s University School of Medicine examined the likely impact of the recession on medicine. The main themes that emerged from the discussion illustrate the broad potential impact that the economic policies underlying the recession, can have on medicine and health care:

Patients

Loss of work and job opportunities increased susceptibility to health problems and to poverty, a major health determinant.

Physicians and professionals

Greater obstacles to studying medicine, particularly for students from lower income backgrounds.

Threat to residency places, job opportunities and physician remuneration. Decreased research funding, as well as re-allocation of funds, for instance between prevention and curative interventions.

Health services

An economic recession produces an increased load on medical and social services. Financial crises in health often stimulate reform, leading to reformulation of health policy, setting new priorities and implementing new controls and regulations, such as increasing the accountability for health care spending. Reformulation of health policy may be seen as a threat or as an opportunity for improvement. It can also be an opportunity for promoting privately funded health care as a way to reduce pressure on the public system (see Chapter 12 for reasons why private funding does not reduce pressure on the public system)

Ethics

Recessions challenge the perception of health care as a public good and not a commodity. In our global market for health care services, economic pressures may drain trained care-givers from developing countries where they are most needed. However, those workers may support the economies of their country of origin with the money they send home. The social responsibility of physicians may become more irksome and therefore less respected, leading to ethical questioning of privilege and obligation in the medical profession.

From Noyahr LA, Leung K, Uy P. The economic crisis and medicine forum: a guided inquiry model for exploring topics in medicine and society. Presented at Canadian Conference on Medical Education. St John’s, Newfoundland, May 2010.

 

According to the 1988 WHO Adelaide recommendations,9 healthy public policy is “characterized by explicit concern for health and equity in all areas of policy and by accountability for health impact. The main aim of healthy public policy is to create a supportive environment to enable people to lead healthy lives. Such a policy makes health choices possible or easier for citizens. It makes social and physical environments health-enhancing. In the pursuit of healthy public policy, government sectors concerned with agriculture, trade, education, industry, and communications need to take into account health as an essential factor when formulating policy. These sectors should be accountable for the health consequences of their policy decisions. They should pay as much attention to health as to economic considerations.”

Always look at the big picture

Health policy-making is not easy. It must consider a remarkably broad range of possible costs and benefits; focusing on one aspect of a problem may lead to unexpected harmful consequences, as seen in the story of the Cairo pig farmers.

Garbage, pigs and swine flu10, 11

Until the 2009–2010 H1N1 (swine flu) pandemic, urban pigs flourished in Cairo. They fed on organic household waste, provided a steady income for their owners, and were a cheap source of food for the 10% of the population whose religious beliefs allowed them to eat pork. In early 2009 the Egyptian government culled a million of these pigs in order to resolve the health risk posed by “disorderly pig-rearing” in cities. However, international news media reported that the cull was to prevent the spread of swine flu. The cull had a number of probably unforeseen consequences. First, the Egyptian government was derided for using an inappropriate measure to prevent the spread of swine flu. Second, the urban pig farmers, already a vulnerable, excluded group, lost their source of income. Finally, an excellent waste recycling service was removed, resulting in pressure on the city’s waste removal services which could not cope with the increased volume. Organic waste piled up in the streets, causing a nuisance and possibly a greater health hazard than urban pig farming.

Influences on Health Policy-Making

In strictly economic terms the ideal health care scenario is one in which people demand only what they need and the supply of care would meet their needs. There would be complete overlap of the need, demand and supply circles in Figure 14.1. However, demand is essentially a health behaviour. As such it is subject to all the influences described in models of health behaviour, including advice from professionals and others with vested interests in providing health care. Need, defined by economists, is the capacity to benefit from health care (see Need for care). However there are many differing perspectives on what need is and how it should be defined. For instance, after examining available evidence, in 2001 the Canadian Preventive Care Task Force (described in Chapter 8) concluded that mammography screening for breast cancer in women aged forty to forty-nine was not a need, although, using the same evidence, in 2002 the U.S. Task Force concluded that it was. Furthermore, with little new evidence, in 2009 the U.S. Task Force changed to recommending against routine screening in women under fifty. It is evident that both task forces were subject to influences other than the data that caused variation in their perspectives on the evidence, and thus on their perceptions of what the need was.

The politics of breast cancer screening

The saga of breast cancer screening for women ages 40 to 49 in the United States is perhaps an extreme example of how policy making occurs. For more information, see V. L. Ernster’s “Mammography screening for women aged 40 through 49: A guidelines saga and a clarion call for informed decision making” in the American Journal of Public Health 1997 Jul, 87(7):11036.
For a view of more recent controversy from those responsible for producing guidelines, see S. H. Woolf  “The 2009 Breast Cancer Screening Recommendations of the US Preventive Services Task Force”. JAMA. 2010;303(2):162-163.

Figure 14.1: Factors influencing policy in health care12
Figure 14.1: Factors influencing policy in health care12

There is money to be earned by supplying health care. In Canada, it accounts for about 20% of all government spending.13 Each year, billions of dollars go to purchase all kinds of goods and services, including professional and non-professional services, high- and low-tech equipment, and pharmaceuticals.14 Furthermore, other sectors are also interested in attracting government spending: education, welfare, infrastructure, among others, all have convincing reasons for money to come to them. As a result, many different groups are interested in the policies that govern spending on health and promote their agendas, sometimes quite aggressively. Although most agree that the patient’s interests come first, patient-centred care is a long way from being a reality. Issues such as the public/private mix in health care, primary health care reform, and inter-professional scope of practice sometimes reveal deeply rooted power struggles between professional groups, health care institutions, and other interested groups—even to the extent that the needs of patients and populations are overlooked.15

A perspective on policy making16

Policy-making is a formal struggle over ideas, values and interests, played out by the rhetorical use of language; it is much more than merely turning evidence into practice. Scientific evidence answers the question “What works?” Policy-making is about “What do we do?” Ostensibly, scientific research is about the objective establishment of facts; in fact, it is value-laden. The values of the researcher form the assumptions underlying the research question, as well as the interpretation of the findings. One only has to look at the letters page of a quality scientific journal to guess that there is no such thing as hard evidence—there are only competing constructions of evidence, which can support widely differing positions.

Policy-making is essentially about using judgment. In practice, it depends on what is said, by whom, and whether others find the arguments persuasive. Arguments are composed of logos (the facts and the reasoning), pathos (the emotional content), and ethos (the credibility of the speaker and the way the argument is presented). A persuasive argument uses all three elements to penetrate.

The Policy Cycle

Policy-making is a complex, involved, and continuous process. The history of tobacco illustrates how policies on tobacco production and consumption have changed since its arrival in Europe. It took nearly fifty years from the time Doll and Hill published a study showing the harmful effects of smoking tobacco17 to the passing of effective legislation against it in Canada.

Many policy analysts use the policy cycle as a framework to understand the process of how policies come about.18 The policy cycle describes how an issue moves from its initial inception through to implementation, evaluation and a new agenda. Table 14.3 summarizes the cycle; note the parallel between the policy cycle and the PDSA cycle of quality improvement (see Figure 13.3).

Table 14.3: Problem solving and the policy cycle. From Howlett and Ramesh 199518

Five stages of the policy cycle and their relationship to applied problem solving
Stages in policy cycle Phases of applied problem solving Description and comments
1. Agenda setting Problem recognition How an issue comes to the attention of policy makers. The process is not always rational, and it can often be difficult to see why some issues rise to the top of political agendas while other, seemingly more important issues, remain unaddressed19
2. Policy formulation Proposal of solution Decision-makers (governments, health regions, hospitals, care teams etc.) formulate policy options. Government policy-making usually occurs behind the scenes and is carried out by professional policy analysts19
3. Decision-making Choice of solution How decision-makers decide what to do—or not do—about an issue
4. Policy implementation Putting solution into effect Putting the decisions into effect. Not as simple as it sounds, as it usually entails changing habits and ingrained ways of doing things
5. Policy evaluation. Monitoring results (all too often neglected) Examining implementation and outcomes to check if the policy has been properly implemented and if the desired outcomes were achieved18, 20

It is tempting to think of policy-making as an ordered process that moves logically forward, through each step of the cycle. However, the real world is chaotic. The reality is that the process can begin at any of the steps and does not always move in logical sequence through all the steps. Sometimes policies are formed without adequate definition of the problem or without consideration of possibly better alternatives. Those who want to change policy must always be on the look-out for opportunities and influences that will help advance their position. Achieving policy change generally depends more on tenaciousness, patience and persuasive argument than on scientific evidence.

Although evidence is used to inform the policy-making process, budgets and the feasibility of implementation dictate choices. Even if budgets and implementation are not obstacles to acting according to evidence, the questions asked of the evidence and how the replies are interpreted can result in widely different viewpoints.

Politics of prevention

The University of Ottawa website summarizes the story of petroleum companies opposing efforts to ban lead in gasoline.

The National Collaborating Centre for Healthy Public Policy covers the history of Canadian tobacco policy.

Industry: a political force

Industry succeeds in selling products long after they are shown to be a probable hazard to health.

Here are some of the methods they use:2

  1. Public Relations
  • Express a concern for the health of the users of the product. In 1954, the US tobacco industries produced a statement saying that their top executives accept an interest in people’s health as their basic responsibility. Obviously, people with such an interest would never sell a harmful product.
  • Stress personal responsibility and the freedom of the individual. Industry claims to provide choice for individuals: “Just because we have electricity doesn’t mean that you have to electrocute yourself.” Of course, industry claims, advertising simply informs.
  • Funding civic activities and demonstrating social responsibility. In 2000, the Philip Morris tobacco company spent $115 million on social causes in the U.S. and a further $150 million to publicize its beneficence. This $265 million was 1.7% of the company’s domestic tobacco revenues.
  1. Influence government and key organizations
  • Election campaign contributions. Some companies contribute funds to all the major parties in order to buy favour with the candidate who wins the election.
  • Many companies retain the services of lobbyists who plead the company’s cause to those in power.
  • Revolving door between private organizations and public bodies and government. Industry may hire scientists as advisors in an attempt to colour the interpretation of results of scientific study. Future jobs can be promised to members of government.
  • Funding for “grass roots” groups. Some companies fund pressure groups that masquerade as consumer groups.
  1. Create doubt and influence the results of scientific enquiry
  • Dispute generally accepted scientific results. Harshly criticize studies that find against their interests and discredit the source of the study.
  • Fund scientific projects to produce good will and influence reporting of results. Studies funded by industry are more likely to report results in favour of the industry than studies not funded by industry.
  1. Product marketing
  • Target youth. Influencing the habits of young people can ensure that products are consumed for a lifetime.
  • Product placement. The common method is for the hero of a movie or television show to be seen using the product on screen. Other approaches include the sale of fast food, junk food, and soft drinks in schools or hospitals, which are assumed to endorse the products sold on their premises.
  • Offer “safer” versions of the product. “Light” cigarettes are generally only light when smoked by the machines that measure nicotine and tar content. When humans smoke them, the smoker’s fingers block the ventilation holes. Low fat cereal alternatives often have higher sugar content than the original products.
  • Create addiction. The tobacco industry has modified nicotine levels to make their products more addictive.

The Budget Cycle

Whereas the policy cycle is sometimes almost pure theory, the budget cycle is concrete. The financial year is highly structured and budget-making follows a strict schedule. Although the schedule varies between organisations and from year to year, there is a fairly predictable pattern. A typical government budget cycle is illustrated in Figure 14.2. In this cycle, policies that require a reallocation of budget must be adopted by early to mid-autumn if they are to be implemented the following year. Early in the New Year, the budget is, for all intents and purposes, finalized, although it is not made public until March.

Figure 14.2: A Canadian government budget cycle22
Figure 14.2: A Canadian government budget cycle22

 

Economic analysis

Economic analysis is the “the comparative analysis of alternative courses of action in terms of both their costs and their consequences.”23, 24 Although economic analysis provides ostensibly hard evidence on which to base decisions, results depend on which costs, harms, and benefits are considered, as well as to whom they accrue. Four approaches to economic analysis (cost-benefit, -effectiveness, -utility and -minimization) were outlined in Chapter 7.

Costs can be monetary or non-monetary, such as loss of a limb, loss of a life-year, or psychological suffering. There are significant methodological questions over how best to value these non-monetary costs as well as how to compare different health and social outcomes.23-28

Two examples of economic evaluations

A cost-utility analysis

In many Canadian provinces, at least two doses of hepatitis B vaccine were given to nine-to-eleven year-olds (the age depends on the province). The hepatitis A vaccine is given only to those at risk of the disease. A study examined the cost-utility of adding Hepatitis A vaccine to the doses of hepatitis B vaccine given. It found that the bivalent (hepatitis A and hepatitis B) vaccine, even though it incurs additional health costs, is cost-saving from a societal perspective. The analysis included consideration of the gain of QUALITY-ADJUSTED LIFE YEARS (QALYs). It found that the net benefit of using the bivalent vaccine in all nine-to-eleven ten year-olds instead of the monovalent hepatitis B vaccine would be an additional 49 QALYs for Canada.25

A cost-benefit analysis

Reducing dietary sodium by 1,840 mg/day (as opposed to not reducing it) would decrease the prevalence of hypertension by 30%, resulting in one million fewer hypertensive patients in Canada. Direct savings to the Canadian health care system would be about $430 million per year because of the reduction of costs due to reduced use of medications, laboratories and physician visits.26

Although economic analysis provides ostensibly hard evidence on which to base decisions, results depend on which costs, harms, and benefits are considered, as well as to whom they accrue. Economic analyses will continue to form a cornerstone of health policy planning and physicians will find that economic considerations frequently conflict with their mandate to focus on what is best for the individual patient.

Public Health Ethics

Public health ethics can be distinguished from bioethics by differences in emphasis:

  • Population focus vs. focus on individual
  • Community perspective vs. focus on the person
  • Social determinants vs. individual agency and responsibility
  • Systems of practice vs. individual decision-making
  • Distribution of resources vs. patient care.

Public health ethics become relevant to clinicians when they plan projects directed at their practice population—for example, implementation of screening guidelines or vaccination programmes. They can also impinge on ethical considerations relating to individuals in situations when the health of the population is at risk. The central values of clinical ethics, such as autonomy, individual liberty, beneficence and non-malfeasance, relate to the interaction between clinicians and patients. Public health, focussing on the community, has a wider range of values, including:29, 30

  • Solidarity
  • Social justice and equity
  • The protection of collective interests
  • Notions of community (including respect for community)
  • Common goods and public goods
  • General societal well-being and human flourishing
  • Reciprocity
  • Public trust.

Several frameworks have been developed to assess the ethics of public health action;30-34 each one highlights a particular perspective. As public health develops, its ethical frameworks are also likely to continue to evolve. Ethical frameworks help identify the range of issues to be considered before deciding on an action. They do not identify the ‘right’ decision;35 they are just ‘frames,’ a way of looking at a problem. They aim to assist the decision-maker, but judgment on the decision-maker’s part remains essential.

Ethical issues relevant to public health actions

Justifiability: What are the goals of the action? The goals should be publicly justifiable.

Transparency: Is the decision-making process transparent? All those affected by the action should have input into the decision.

Effectiveness: Is the action capable of achieving the goals? “The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant” (John Stuart Mill).

Necessity: Must one intervene? Is there another way of achieving the same goals? If there is more than one way, that which causes the least harm should be chosen.

Proportionality: Do the benefits outweigh the harms that the action causes? In the SARS outbreak, civil liberties had to be balanced against the need to quarantine; the protection of health workers had to be balanced against the duty to provide care, and enabling access to care had to be balanced against the need to reduce infection spread.

Minimization of harm: Can any harm caused by the action be reduced? Harm includes infringement on general moral principles. For instance, if it is necessary to break patient confidentiality to protect the population, only essential information should be communicated, and those responsible for gathering that information should ensure its security.

Reciprocity: Can individuals be compensated for the harm the action causes? For instance, individuals who suffer secondary effects of vaccination should have free access to the care and rehabilitation they need.

Fair balance of benefits and harm: Is it likely that one sector of the community will benefit while another is harmed, or are the harms distributed equally? For instance, people living near a polluting factory are likely to derive health benefits if the factory is closed, but those working in it will suffer the harm of job loss.

Fair implementation: Will the action benefit all sectors of the community? Health campaigns aimed at a general population run the risk of reaching only the best-informed section of society that is least in need of them.

 

Ethics beyond humans

Some recent frameworks, developed to examine global and international moral challenges, include respect for all life and for the environment.34 Indeed, experts are beginning to call for an expansion of the discourse on ethics from interpersonal relationships to the ethics of relationships between institutions and even to the ethics of relationships between nations. This will require promotion of a deeper understanding of citizenship in an interdependent world, commitment to an extended range of human rights, and new ways of thinking about ourselves, our relationship to others, and to the ecological system. In addition, human rights should be linked to a broader moral agenda embracing the duty to meet essential human needs and to achieve greater social justice within and between nations. From this springboard we can move to an expanded discussion of public health ethics and its implications at the international and global levels.

Public health ethics and clinical practice

At times, public health considerations require clinicians to break the code of ethics that governs the care of the individual:

  • Reporting a notifiable disease requires a breach of patient confidentiality that, generally, does not benefit the patient. It is required by law in order to assist in the monitoring and control of infectious disease with the aim of benefiting the public.
  • Cooperating in epidemiological investigations or intervening to control the spread of disease may also require the physician to carry out an intervention that is of no benefit to the patient.
  • Isolation and quarantine restrict patients’ freedom.
  • Prophylaxis or vaccination of contacts to prevent the spread of infectious disease may not greatly reduce the contact’s risk of disease, so the benefit to the contact may not outweigh his risk.

Although public health legislation in the Canadian provinces allows Medical Officers of Health to transgress certain individuals’ rights in order to protect the population from illness, the harm to individuals should always be minimized. Reports of notifiable disease are confidential and should be kept under secure conditions. Treatment or isolation of a patient against his will requires legal intervention; the Medical Officer has to present the case before a judge or a magistrate.

A major ethical question for all clinicians concerns how to balance their duty to care for the patient with their duty, as a manager of scarce resources, to ensure equity in allocation of resources. Most health care spending results from decisions made by individual clinicians with individual patients. Inefficient or ineffective clinical intervention in one patient wastes resources that could be used to treat another patient or, indeed, used in another sector—education, housing or employment.

Some ethical perspectives relevant to public health36

Utilitarianism

Jeremy Bentham (1748–1832) argued that the rightness of an action is not intrinsic but is determined by the “hedonic calculus” of counting up the pleasure and pain it produces. Translated to public health, policy or action should be judged by its effect on the sum of individual levels of well- or ill-being it produces. However, the measurement of well-being, the outcome of the action, is subject to discussion: whether individuals’ perceptions of their own well-being or objective measures should be used; how to weigh ‘apples against oranges’ (as an example, can dyslexia be compared to the loss of a foot?); or the relative value of harm at different ages. The utilitarian approach is often used in public health, for instance a childhood vaccination programme entails vaccine reactions in some children in order to reduce the larger number of children who would be harmed by the disease; the quarantine of a person with infectious disease entails restriction of that person’s freedom in order to prevent the harm to others that transmission of the disease would cause.

Liberalism

Immanuel Kant (1724–1804) held that human beings ought to be treated with respect, as ends in themselves and not as means to another individual’s ends. The approach promotes individual freedom of choice; however, how to achieve it is a matter of debate. Some want minimal government intervention to protect personal liberty. Others argue that the right to choice is meaningless without adequate resources to enable choice, so that health care must be made affordable. Once this happens, health care can be matter of choice. There is also debate over whether health is a prerequisite for choice or a consequence of it. If it is a consequence of choice, governments should provide access to health care and education on how people can improve their health, but allow individuals to decide on whether or not to use these. If health is a prerequisite for choice, governments can be more aggressive, using legislation to coerce people into healthy behaviours, such as using seat belts or not smoking.

Communitarianism

This perspective has a long history. It is found in the Greek philosophers Plato and Aristotle, as well as in many non-western traditions. It focuses on the creation of a good society. Knowing one’s place and fulfilling one’s duties are important virtues. The major question of this perspective is: Who decides what is virtuous? One view is that every community defines its own norms so that morality is contextualized; each society or culture must respect the norms of the other. Others believe in a single true form of good society and its associated virtues. With this belief, it is possible to promote cultural patterns, such a female literacy, in all societies. Communitarianism also leads to questions about how much coercion may be used to limit deviancy from norms. Finally, it raises questions about how to define ‘a community’, that is, when can an individual or group be allowed to opt out to follow a vision different from that of the main community?

Public health ethics

To read more about public health ethics: Bailey TM, Caulfield T, Ries NM (eds). Public health law and policy in Canada. 2nd ed. Markham (ON): LexisNexis Canada, 2008. Chapter 2 covers public health ethics: pp. 37-59.

Self-test questions

1. What are the main steps in policy-making?

The main steps of policy-making in theory are:Agenda-setting during which priorities are identified,

Policy formulation during which policy options are identified,

Decision-making to select the preferred policy option,

Policy implementation during which policies are put into effect,

Policy evaluation during which the implementation and the effect of the policy is assessed.

In practice, although these steps are useful in analysing how policies are made and implemented, they are rarely followed in an orderly manner.

2. What is the different between policy and politics?

Politics is the art and science of government, or the activities concerned with the acquisition or exercise of authority or power. Policy refers to a course or principle of action. In other words, politics are what makes policy.

3. Define the term healthy public policy.

Healthy public policy includes all policies that are likely to impact health, whether or not health is their primary aim. They include policies relating to transport, the environment, the social system, the economy, and the education system, among many others.

4. What are the main differences between clinical ethics and public health ethics?

The outstanding characteristic of clinical ethics is the unequal power relationship between the patient and the professional. The outstanding feature of public health ethics is the dilemma created by weighing the rights of different individuals in populations. The two are distinguished by virtue of their different emphasis.

Emphasis in public health Emphasis in clinical medicine
Population focus Individual focus
Community perspective Personal perspective
Social determinants Individual agency and responsibility
Systems of practice Individual decision-making

The central values of clinical ethics relate to interaction between professionals and patients and deal with issues such as autonomy, individual liberty, beneficence and non-malfeasance. Public health values are broader and include solidarity, social justice and equity, protection of collective interests, common and public goods, societal well-being, reciprocity and public trust.

 

Reflection Questions

  1. A patient suffering from multiple sclerosis has requested that you write a letter of support so that he can get venous decongestion at the expense of the province. The promoters of this treatment claim that it improves the symptoms to the extent that patients can regain lost functions. The medical establishment, however, considers that the scientific basis of the treatment is lacking as is evidence of its effectiveness. Discuss the ethical issues involved in your decision.
  2. What are the main health care priorities in the region in which you work or study and what were the criteria for identifying them as priorities?
  3. Describe a policy in the municipality where you live that affects your health.

References

  1. Ackerknecht EA. Rudolph Virchow: Doctor, statesman, anthropologist. Madison: University of Wisconsin Press; 1953.
  2. Rachlis M. Prescription for excellence: how innovation is saving Canada’s health care system. Toronto: Harper Collins; 2004.
  3. Barber K. Canadian Oxford dictionary. Toronto & New York: Oxford University Press; 2000.
  4. Lasswell H. World politics and personal insecurity. New York: McGraw-Hill; 1935.
  5. Barker C. The health care policy process. London: Sage Publications; 1996.
  6. Frenk J. Dimensions of health system reform. Health Policy. 1994;27(1):19-34.
  7. Terris M. The complex tasks of the second epidemiologic revolution: the Joseph W. Mountin lecture. Journal of Public Health Policy. 1983;4(1):8-24.
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