Public health: ethical issues
Nuffield Council on Bioethics –
Available online PDF [225p.] at:
http://www.nuffieldbioethics.org/fileLibrary/pdf/Public_health_-_ethical_issues.pdf
“…..In this Report the authors consider some of the ethical issues that arise from efforts to improve health at the population level, and we examine the roles and responsibilities of the different parties involved. Although some might see personal behaviour as the primary factor determining the health of the population, we consider that to be too simplistic.
Individual behaviour certainly plays a role, but health is influenced by many factors, such as clean air, the built and work environment, socio-economic and genetic background, and access to healthcare. Industries such as those producing, selling and marketing food, drink and tobacco also play an important role, and the impact of almost all these factors is influenced directly or indirectly by government policy…”
Table of contents
Foreword
Executive summary
Chapter 1: Introduction
Background
Factors affecting population health
The concept of ‘public health’
Public goods and public services
Outline of the Report
Chapter 2: An ethical framework
Introduction: an ethical framework for policy
The state and the citizen
Libertarians versus collectivists
The liberal state
AutonomyHealth as a value
A liberal proposal
Mill’s harm principle
Public health and the harm principle
An initial liberal framework
Broadening the debate
Individual consent and its limitations
Health inequalities
Changing habits and the limits of information-only approaches
Adding a social dimension
The value of community
Paternalism
A revised liberal framework: the stewardship model
Discouragement and assistance
Third parties
Business
Summary
Chapter 3: Policy process and practice
Introduction
Evidence
Risk
Precaution and proportion
Choice
Vulnerable groups, health inequalities and targeted interventions
Social inequalities in health
Targeting disadvantaged groups
Targeting at-risk groups
Universal provision
Behaviour change
The intervention ladder
Stakeholders and policy making
Economics
The policy-making debate
Summary
Chapter 4: Case study – Infectious disease
Effects and 'costs' of infectious diseases
Causes of infectious diseases
Prevention of infectious diseases through vaccination
Why vaccinate?
Benefits and risks of vaccination
Risks
Weighing up benefits and risks
Alternative approaches to vaccination: voluntary, quasi-mandatory and incentivized schemes
Comparing and assessing vaccination strategies
Children as special cases
Vaccinations in the media
Surveillance
Broad surveillance for research and monitoring trends
Collection and use of surveillance data and consent
Surveillance to detect cases of disease that require intervention
HIV and AIDS as notifiable diseases
Surveillance in an international context
Control of infectious diseases
Issues raised by quarantine and isolation
Use of vaccines in control of infectious diseases
The importance of information in the case of an epidemic or pandemic
Summary
Chapter 5: Case study – Obesity
Obesity: impact upon health, prevalence and causes
Effects of obesity on health
Prevalence of obesity
Understanding the causes of obesity
The challenge of reducing obesity
Roles of different parties in reducing obesity
Role of the food and drink industries – corporate social responsibility
Food advertising to children
Labelling and composition of food
Role of government and public services
Promoting healthy living through enabling choice and behaviour change initiatives
Strategies for reducing inequalities
Interventions for protecting vulnerable groups
Interventions for protecting others against harm
Consideration of obesity-related treatments and costs to the NHS
Role of civil society and individuals
Summary
Chapter 6: Case study – Alcohol and tobacco
Harms caused by alcohol and tobacco to drinkers and smokers themselves
Alcohol
Smoking
Addiction
Harms to other people associated with alcohol and tobacco
Entitlement to treatment and costs to the NHS
Obligations of the alcohol and tobacco industries
Advertising
The tobacco industry: harm reduction
The tobacco industry: international aspects
Role of government
Protecting the vulnerable
Enabling people to live more healthily and make choices (provision of information)
Summary
Chapter 7: Case Study – Fluoridation of water
Dental health in the
Water fluoridation
Background to fluoride and water fluoridation
Benefits and harms of water fluoridation
Extent of water fluoridation in the
Alternative fluoride-based measures
Ethical considerations in fluoridation of water
Principles that may be used in favour of water fluoridation
Reduction of risks of ill health
Special care for the health of children
Reducing health inequalities
Principles that may be used against water fluoridation
Not intervening without the consent of those affected
Minimise interventions that affect important areas of personal life
Not coercing ordinary adults to lead healthy lives
Personal values
Reducing inequalities
Reducing ill health by ensuring environmental conditions that sustain health, and caring for the health of children
Alternatives to water fluoridation
Consent
Evidence and information
Evidence
Information
Chapter 8: General and overarching conclusions
Ethics: observations
Hierarchy of principles
Collective efforts of society versus individual action
Conflicts involving third parties
Specific policy issues
Paternalism, public health policy, and health and safety policy
Use and communication of evidence
Consistency and conditions of enforceability
International dimensions of public health
Targeting
Monitoring
Appendix 1: Method of working
Appendix 2: Wider consultation for the Report
Appendix 3: Vaccination policy – the international context
Appendix 4: Obesity policy – the international context
Appendix 5: Fluoride for dental health – the international context
Appendix 6: Alcohol and tobacco policy – the international context
Appendix 7: Reports by other organisations
Glossary
List of abbreviations
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