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

Public Policies and Health

As early as the 19^th 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 such statements can be found in Chapter 2, which showed how the social determinants of health include the economy, the political system, and culture as a whole.

HEALTH POLICY choices or issues fit into four major groups according to the level at which they affect the system: ^{5, 6}

• Systemic issues concern the main influences 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 choices 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 be developed and funded?”
• Organizational choices concern the way in which resources can be used most 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 choices 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. Service reductions generally fall in this category. In Canada, discussions surrounding the tenets of the Canada Health Act nearly always fall in this category, especially those surrounding private versus public payment for health services.
• Low political issues are 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 react to changing 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 developed 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

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 determinants of health like housing or potential environmental exposures. And policies concerning social inequity, social exclusion and access to education can also influence health.⁷ In other words, improvements in health policy alone are insufficient; healthy public policies in other fields of government 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

Evaluating the health impacts of public policies is a developing field in public health. The aim is to assemble evidence on the effects of polices such as the fluoridation of drinking water, transportation, or urban planning policies. Public policy evaluation assesses the effects of the policy (effectiveness, unintended effects, and equity), the implementation of the policy (cost, feasibility, and acceptability), and the durability or sustainability of the policy.

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.”

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.

Demand can be considered a health behaviour. As such it is subject to all the influences described in models of health behaviour (see Chapter 2), including social and cultural influences, and advice from professionals and others with vested interests in providing health care. Need is more difficult to define but is intended to be an objective judgment. A key concept, originally proposed by economists, is that need is the capacity to benefit from health care: there is no real need for an ineffective treatment. This approach forms the basis for the work of Choosing Wisely Canada, which works with clinical specialists to identify and develop recommendations on frequently overused tests and treatments that do not add value to patient care.¹⁵

There is money to be earned by supplying health care. In Canada, it accounts for about 20% of all government spending.¹⁷ Each year, billions of dollars are spent to purchase all kinds of medical goods and services, including professional and non-professional services, high- and low-tech equipment, and pharmaceuticals.¹⁸ Furthermore, other sectors are also interested in attracting government health spending: education, welfare, and infrastructure, among others, all making convincing arguments that money should come to them. As a result, many rival groups are interested in the policies that govern health spending on health and promote their agendas, sometimes quite aggressively.

Within the health care system, and although most agree that the interests of patients should 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.¹⁹

The Policy Cycle

Policy-making is a complex, involved, and continuous process. The history of tobacco control 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 tobacco²¹ to the passing of effective legislation against it in Canada.

Many frameworks are used by policy and public health professionals to help guide their work. The policy cycle is one framework that clarifies the process of how policies are produced.²² 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, 1995²²

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. In reality, the process can begin at any of the steps and does not always move in a logical sequence through each step. 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.

Evidence may be used to inform the policy-making process, but 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.

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 not made public until March.

Economic analysis

Economic analysis is the “the comparative analysis of alternative courses of action in terms of both their costs and their consequences.”^{27, 28} 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.^27-32

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

Ethical frameworks help identify the range of issues to be considered before deciding on an action. They do not identify the “right” decision;³⁴ they just offer “frames,” or ways of looking at a problem. They aim to assist the decision-maker, but judgment on the decision-maker’s part remains essential.

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, such as implementing screening guidelines or vaccination programmes. The problem is that in situations when the health of the population is at risk, public health ethics can conflict with individual ethical considerations. The central values of clinical ethics, such as autonomy, individual liberty, beneficence, and non-malfeasance, relate to interactions between clinicians and patients. Public health, focusing on the community, has a wider range of substantive and procedural values, outlined in Table 14.4.^{35, 36}

Table 14.4 Substantive and procedural values underlying public health practice

Several frameworks have been developed to assess the ethics of public health action;^36-40 each highlights a particular perspective. As public health develops, its ethical frameworks are also likely to continue to evolve.

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 harms: Is it likely that one sector of the community will benefit while another is harmed; 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.

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’ freedoms.
• Prophylaxis or vaccination of contacts to prevent the spread of infectious disease may not greatly reduce their risk of disease, so the benefit to the contact may not outweigh their 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, individual harm should always be minimized. Reports of notifiable disease are confidential and should be kept under secure conditions. Treatment or isolation of a patient against their 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 allocating resources. Most health care spending results from decisions made by individual clinicians with individual patients. Inefficient or ineffective intervention in one patient wastes resources that could be used to treat another patient or, indeed, used in another sector—education, housing or employment.

Self-test questions

References 

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