The contribution of ethics to public health

Abstract

While ethics in health care dates back at least to the times of Hippocrates, Sun Si Miao,1 and Ibn Sina (Avicenna),2 the field of “bioethics” did not emerge until after World War Two. The birth of bioethics was stimulated by a confluence of factors. First, the Nazis’ medical experiments on concentration camp prisoners heightened concerns about the vulnerability of human subjects in medical research. Second, rapid advances in medicine, including reproductive health, organ transplantation and genetics, raised questions about the purpose and limits of medical technology. Third, post-war civil rights movements led to growing attention to the power imbalances between physicians and patients and the corresponding need to empower patients to control their own health-care decisions. In recent years, there have been efforts to broaden the scope of ethical analysis in health care to focus more directly on public-health issues.3 In contrast to the traditional emphasis of bioethicists on the physician–patient relationship, public-health ethics focuses on the design and implementation of measures to monitor and improve the health of populations. In addition, public-health ethics looks beyond health care to consider the structural conditions that promote or inhibit the development of healthy societies. From a global perspective, key issues in public health ethics include the following: Disparities in health status, access to health care and to the benefits of medical research – For example, questions about resource allocation depend in part on value judgments about the relative importance of small improvements in quality of life for a large portion of the population as compared with a life-saving intervention that would benefit only a few people. Responding to the threat of infectious diseases – Efforts to contain the spread of infectious diseases raise difficult questions about the appropriateness of restricting individual choices to safeguard other people’s welfare. Examples include the use of isolation and quarantine for tuberculosis and pandemic influenza. International cooperation in health monitoring and surveillance – The implementation of the International Health Regulations4 reflects the commitment of countries to collective action in the face of public-health emergencies. Defining the scope of countries’ obligations to act collectively, and determining how those obligations should be enforced, will inevitably raise difficult ethical dilemmas. Exploitation of individuals in low-income countries – Current practices in medical research, for example, may expose participants to significant risks without a benefit for themselves or their communities. Defining and enforcing foreign research sponsors’ obligations to local participants is therefore a critical ethical issue. In the area of organ transplantation, the growing practice of “transplant tourism” exposes individuals living in poverty to significant health risks while also raising broader questions about the commodification of the human body. Health Promotion – The growing public-health threats of noncommunicable diseases, including those caused in part by unhealthy behaviours such as smoking, poor diet or lack of exercise, have raised the question of the extent to which public-health authorities should interfere with personal choices on health. Participation, transparency, and accountability – As an ethical matter, the process by which decisions are made is as important as the outcome of the decisions. In the area of medical research, much attention has been devoted in recent years to strengthening systems for informed consent and community oversight. Once such systems are in place, the next step will be to develop mechanisms for evaluating their effectiveness. Since it was founded 60 years ago, ethics has been at the heart of WHO’s mission to protect and promote the global community’s health. Activities in ethics have been undertaken by many programmes and departments, as well as WHO’s regional offices. For example, in 1994, the Regional Office for the Americas (AMRO/PAHO) created a regional programme on bioethics5,6 In 2002, WHO’s Director-General Dr Gro Harlem Brundtland created an Ethics and Health Initiative, which has since served as a focal point for the ethics activities throughout the organization. Examples include the publication of Guidance on ethics and equitable access to HIV treatment and care (jointly with UNAIDS)7 and of Ethical considerations in developing a public health response to pandemic influenza.8 WHO also contributes to regional capacity-strengthening efforts in ethics, in close collaboration with Member States. For example, the project Networking for Ethics on Biomedical Research in Africa (NEBRA) sought to strengthen African countries’ capacity to engage in effective ethical review processes.9 Articulating ethical and evidence-based policy options is one of WHO’s six core functions.10 WHO’s 60th anniversary and the 30th anniversary of Alma-Ata provide a particular opportunity to reflect on ethical values and dilemmas arising in the field of public health. ■