E. Values and Principles in Public Health Ethics

Some Proposed Values and Principles for Public Health Ethics

We generally know what values and principles are but they’re hard to describe.

Values can be thought of as relative weights of the importance of things, of how much things matter to us. An ethical value is one that particularly concerns the well-being or interests of others. Some are unmistakably ethical values and some are not. For example, you might value social justice (there is a clear ethical dimension to social justice) and also value playing tennis (while all of our actions have ethical dimensions, valuing the game of tennis is, on the face of it, more ethically neutral).

Principles often take the form of the rules of the game, the accepted norms we abide by in order to proceed in a particular context. It is important to note that they are contextualized to one or another body of knowledge or sphere of action. They might be considered as the starting points, the taken for granted truths that serve as the knowns, or the foundations from which you proceed, or the basic rules by which you proceed. In various disciplines, principles serve to anchor and structure the possibilities within that area.

In ethics, principles are assertions that something matters, and that this something should matter to anyone. An ethical principle is a value statement, worded in an imperative form to say ‘this ethical value should matter to you too, and it should be taken into account accordingly’. It would not be appropriate to treat all values like this, but it makes sense for ethical values.

Ethical Value

• Ethical quality that matters to you
  • e.g., Social Justice

 

Ethical Principle

• Rules or guidelines informed by values
  • e.g., "I will raise awareness about health inequalities"

Someone may, in certain contexts, reasonably ask you to justify an ethical principle: ‘Why should this matter to me?’ Justification is another matter, and it’s a longer story. The short version is that you want the ethical principles that are used to inform decisions to be justified or backed up in one way or another, but we do not usually do so explicitly. The theoretical, justificatory underpinnings of ethical principles, that which gives them their moral force, are contested in ethics, in political philosophy and elsewhere, and are beyond the scope of this module. That said, we tend to use principles that are broadly accepted. “Accepted” does not in any way imply that people have a common understanding of the meanings of the principles, or of the words they use to talk about ethics; nor does it mean universally accepted.

Some Proposed Principles for Public Health Ethics

The list of principles below (and the very brief definitions) may help to get you started when considering ethical issues that are relevant to public health programs, interventions and policies. When you consider a proposed initiative, it can be helpful to think about different values and principles and how they can provide a kind of lens into how the well-being of different people and groups might be enhanced or diminished by that initiative. For example, equity is a key value, and taking up equity as a principle will help us to consider the impacts on equity that our initiative might have. Likewise with other principles: they serve as lenses, asking us to consider, for e.g., Is confidentiality respected or not? Is public participation fostered? Are the processes transparent in order to further public accountability, participation and trust; or are they the opposite? As we shall see later, ethics frameworks tend to highlight these values and principles in order to have us reflect on them, so that we might see them better.

Substantive Values/Principles

These are the values that underlie and inform public health activities, policies or programs (e.g., Why bother to implement a vaccination program? How do we improve the level of health, to reduce harm, and/or enable healthy and productive lives, balancing such gains against risks to individuals, opportunity costs of foregone programs, etc.). Put simply, substantive values relate to ‘what we want to do?’ in that they are “the criteria […] on which a policy or decision are based” (Kenny, Melnychuk and Asada, 2006, p. 403).

Procedural values/principles

While substantive values inform programs and activities in public health in terms of what to do, procedural values affect how those activities, programs and policies are implemented. Procedural values relate to ‘how do we want to get there?’ in terms of “the appropriate and fair process for development, implementation and evaluation of the policy” (Kenny, Melnychuk and Asada, 2006, p. 403). In reality, the boundaries between substantive and procedural (between ‘what’ and ‘how’) are not always clear.

Substantive Values/Principles:

Beneficence

The obligation to help, to do good for others.
“Prevention [of harm] and removal [of harmful conditions] require positive acts to benefit others, and therefore belong under beneficience” Beauchamp & Childress, 1994, p. 259. (The more specific professional duty to provide care could fall under beneficience.)

Confidentiality

A duty to protect other people’s privileged information.
“The obligation to keep information secret unless its disclosure has been appropriately authorized by the person concerned or, in extraordinary circumstances, by the appropriate authorities” WHO, 2007, pp. 5-6.

Duty to provide care

A professional has an obligation to help. I.e., to provide care and to respond to suffering. This obligation is balanced against risks to self, family and others and is not absolute. U of T JCB, 2005, pp. 6-8.

Distributive justice

“This ethical principle requires that the risks, benefits, and burdens of public health action be fairly distributed” WHO, 2007, p. 7. See also social justice/equity, as these both relate to the fair distribution of risks, benefits, burdens, rights, opportunities, power and self-respect.

Effectiveness

Because interventions impose various kinds of costs, they should work. A public health intervention that impinges upon other social values, such as “liberty restriction in the name of public health protection should be based on evidence that the intervention in question would in fact provide an effective means of public health protection” Selgelid, 2009, p. 202.

Efficiency

“[B]enefits should be obtained using the fewest resources necessary” WHO, 2007, p. 5. Efficiency is connected to utility: we should do the most good (and least harm) for the most people possible.

Equity/Social justice

Social justice requires us to “correct patterns of systemic injustice among different groups, seeking to correct rather than worsen systematic disadvantages in society” Baylis et al,. 2008, p. 8. Iris Marion Young, 1990, “distinguished social justice from distributive justice. Where distributive justice is concerned with the distribution of finite, quantifiable goods to individuals, [Young] argued that social justice is concerned with fair access to social goods such as rights, opportunities, power and self-respect” Ibid., p. 8. Powers and Faden identify “six dimensions of human well-being to stand as criteria for evaluating the requirements of social justice in the context of public health: health, personal security, reasoning, respect, attachment and self-determination” Ibid.

Harm principle

interfering with an individual’s liberty is only acceptable in order to prevent harm to others; it is not acceptable to interfere with someone for his or her own good. (Mill, 1859): “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”. Cited in, for e.g., Upshur 2002.

Health maximization

We ought to improve health as much as possible for the most people. This is also connected to utility: we should do the most good (and least harm) for the most people we can with what we have.

Least restrictive means

Choose interventions that achieve the desired ends in the least intrusive way. This “recognizes that a variety of means exist to achieve public health ends, but that the full force of state authority and power should be reserved for exceptional circumstances and that more coercive methods should be employed only when less coercive methods have failed” Upshur, 2002, p. 102.

Necessity

Actions should be taken only to address demonstrable threats to health. “Public health powers are exercised under the theory that they are necessary to prevent an avoidable harm” WHO, 2007, pp. 5-6.

Non-maleficence

“The principle of non-malefiecence requires that harmful acts be avoided." […] However, [this] does not preclude balancing potential harms against potential benefits” for individuals and for the public Coughlan, 2008, p. 11.

Precautionary principle

The greater the potential harm, the lower the burden of proof for precautionary action. “[W]hen an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically” Coughlan, 2008, p. 10, citing Kriebel & Tickner.

Proportionality

Interventions should be proportionate to the problems they address so that they don’t produce more harm than good. “[R]estrictions to individual liberty and measures taken to protect the public from harm should not exceed what is necessary to address the actual level of risk to or critical needs of the community” U of T JCB, 2005, pp. 6-8.

Protection of the public

It is a duty to protect the public from harm. This sometimes conflicts with other duties like respect for autonomy and privacy. For example, even “the most highly valued individual liberties have to be balanced against a second value – that of protecting the public from harm caused by the uncontrolled movements of people who may be infectious” Singer et al., 2003, pp. 1342-3.

Reciprocity

One should respond to good or to harm in a fitting and proportional way. Becker, 1990. “The principle of reciprocity holds that society must be prepared to facilitate individuals and communities in their efforts to discharge their duties” Upshur, 2002, p. 102. See Keeling and Bellefleur, 2014.

Reconciliation

reflects the importance of “establishing and maintaining respectful relationships at all levels in Canadian Society” including those between settlers and Indigenous peoples, using the United Nations Declaration on the Rights of Indigenous Peoples as a framework (Truth and Reconciliation Commission [TRC], 2015, p. 190). This means “repairing damaged trust by making apologies, providing individual and collective reparations, and following through with concrete actions that demonstrate real societal change” TRC, p. 16.

Respect for autonomy

recognizes a person’s right to self-determination. Relational autonomy - “embraces […] the fact that persons are inherently social and politically and economically situated beings” Baylis, Kenny, & Sherwin, 2008, p. 7. This means looking at the broader social and political contexts, including power, when considering the way in which individuals’ choices are expressed.

Respect for privacy

reflects “an individual’s right to be free from intrusion or interference by others” Government of Canada, TCPS2. Privacy is the right of persons to control how information about them is gathered, used and shared. “Privacy is respected if an individual has an opportunity to exercise control over personal information by consenting to, or withholding consent for, the collection, use and/or disclosure of information” TCPS2, ch. 5.

Solidarity

acting for the benefit of all, regardless of the degree of personal benefit
“ ‘solidarity signifies shared practices reflecting a collective commitment to carry ‘costs’ (financial, social, emotional, or otherwise) to assist others,’ regardless of whether or not the members of the solidarity group expect to benefit personally in return” Bellefleur & Keeling, 2015, p. 3, citing Prainsack and Buyx, 2011.

Relational solidarity

“aims to expand the category of ‘us’ to ‘us all’. Relational solidarity values interconnections without being steeped in assumptions about commonality or collective identity” Baylis, Kenny, & Sherwin, 2008, pp. 8-10.

Sustainablity

reflects our duties to future generations and to others, including other species. That is, our actions should reflect a concern for equity and for ecological stability. We should not pay for our needs today at the expense of others or at the expense of future generations. Hancock, 1996.

Stewardship

Judicious decision-making, exercise of powers and resource use in keeping with the power and responsibilities entrusted to public health on society’s behalf.

Procedural Values/Principles

Accountability

“To be responsible for and required to account for one’s conduct” Nuffield Council on Bioethics, 2007, p. 177-182.

Participation

the various groups, cultural communities and sectors that are affected by decisions should play a role in informing, designing and deciding what to do.

Reasonableness

“Decisions should be based on reasons (i.e., evidence, principles and values) that stakeholders can agree are relevant…” U of T JCB, pp. 6-8. “Reasonable decision making means: working with alternative options and ways of thinking – working with and reflecting cultural diversity – using a fair process to make decisions – basing decisions on shared values and evidence” New Zealand Ethics Advisory Committee [NEAC], 2007, pp. 5-6.

Responsiveness

services should be responsive to individuals and communities’ needs (Fry, 2007, pp. 8-10), and “there should be opportunities to revisit and revise decisions as new information emerges” U of T JCB, 2005, pp. 6-8.

Transparency

“requires policy makers to ensure that their decision making process is open and accessible to the public, through clear and frequent communication of information” WHO, 2007, pp. 5-6.