The Place of Informed Consent and Community Assent in International Public Health Interventions

Abstract

What should the role and place of individual informed consent and community assent be in international public health interventions in order to support an intervention, whilst satisfying the appropriate ethical standards? In responding to this research question, the dissertation covers public health interventions and public health ethics in international settings, with particular attention being given to transcultural interventions in developing countries. The example used is of public health interventions targeted towards the threat to public health represented by malaria in Africa. The focus is on research-oriented interventions, although public health practice will also be touched upon. The dissertation does not question the vital role of informed consent in medical and clinical research and practice; the concerns are limited to informed consent and community assent in public health, particularly in developing country contexts. The epistemic position taken is that the relationship between theoretical and empirical work in ethics should be one of a mutually supportive feedback. Therefore the dissertation contains a deductive, theoretical, normative-descriptive tranche, as well as an explorative, exemplary empirical, inductive tranche. To this end, a dissertation Deductive – Inductive Feedback Structure that has been developed. The motivation for adopting this approach is that the research question arose from concerns raised by public health practitioners; therefore an approach was necessary that addresses concrete experiences, as well as the theoretical, normative aspects of consent and assent in public health. This epistemic, methodological structure has stimulated the adoption of a ‘System – Driving Force – Target – Transformation Knowledge’ analytical framework in addressing the research question. Regarding the findings and results, the inductive and deductive tranches fail to result in knowledge being produced that enables the research question to be answered. There are two main reasons for this failure. One is that the ethics of public health is at an early stage of development, especially when compared to the rapid developments in the fields of medical and clinical ethics; therefore no ‘appropriate ethical standards’ are yet available. As long as they do not exist, the research question cannot be answered. The second reason is that there is no clarity on what the relationships between informed consent, community assent, and community participation should be in transcultural public health interventions. However, although the research question remains unanswered, paradoxically the objectives of the dissertation: “to offer a support from the field of ethics for transcultural public health interventions in developing countries, and add to the emerging ethics of public health in developing countries with respect to questions concerning community assent” are tentatively achieved. Public health ethics models and approaches are developed; new processes of informed consent and community assent for use in in public health transcultural interventions in developing countries are suggested. An action plan is proposed that works towards resolving the research question. It is concluded however that the ‘doctrine of informed consent’ often referred to in the medical context needs to be transformed in public health into a maxim of transparent planning, and an approach of being open to combine informed consent, community assent, and community multi-level engagement, all in pursuit of protecting individuals and communities, whilst supporting international public health research and practice.