Minutes of meeting held on 21st September 2006
Fri, 16 March 2007
5th meeting
NUFFIELD COUNCIL ON BIOETHICS WORKING PARTY ON PUBLIC HEALTH: ETHICAL ISSUES
Minutes of the meeting held at the Nuffield Foundation 28 Bedford Square, London WC1B 3JS on Thursday 21 September 2006
PRESENT
Professor Sir John Krebs FRS (Chair)
Professor Sir Kenneth Calman KCB FRCS DL FRSE
Professor Tom Baldwin
Professor Roger Brownsword
Professor Trisha Greenhalgh OBE
Professor Sally Macintyre OBE FRSE CBE
APOLOGIES
Dr Raghib Ali
Professor Christine Godfrey
Professor Anne Johnson FmedSci
Professor Jonathan Montgomery
Ms Julia Unwin OBE CBE
Professor Sandy Thomas
SECRETARIAT Mr Harald Schmidt, Ms Catherine Joynson, Ms Julia Trusler
INTRODUCTION BY THE CHAIR
1 The Chair welcomed the members of the Working Party, and noted that Professor Thomas would leave the Council as Director at the end of November to head the OSI Foresight Programme. He outlined the schedule of the meeting and invited members to consider the action points of the minutes of the third meeting.
MINUTES OF THE FOURTH MEETING
2 The Earl Baldwin of Bewdley, who had been invited to the fact finding meeting on fluoridation, had sent written comments on the section of the minutes that related to the fact finding meeting, which had not yet been incorporated. A revised version of that section of the minutes would be circulated in due course. The minutes concerning the business part of the fourth meeting were then approved.
DISCUSSION OF RESPONSES TO THE CONSULTATION
3 Approx 1500 copies of the consultation document had been downloaded from the Council’s website. By 13 September, there had been 54 responses, and 51 since then, a total of 105. 12 respondents had requested an extension of the deadline. The Chair reminded members that responses had been circulated in four batches so far, with a fifth batch tabled for the meeting. A sixth batch, including all late responses, would be circulated in due course, together with an updated summary of the responses. Further to previous discussion by email, members then focussed on salient points raised by respondents to the consultation.
GENERAL POINTS
4 Members agreed that the perspective of a health psychologist would be valuable. Instead of inviting a new member someone with this expertise should be invited in the peer review process.
5 Several comments related to the scope and focus of the Working Party’s project, and a number of suggestions for extension of narrowing down were made. These were discussed and it was agreed that a section in the introduction of the Report should clarify its scope accordingly.
THE DEFINITION OF PUBLIC HEALTH
6 It was agreed to revert to the ‘UK’ definition by the faculty of public health of the Royal College of Physicians, with a clarifying comment that this definition related to a conception of public health as an activity, rather than an outcome.
FACTORS THAT INFLUENCE PUBLIC HEALTH
7 Members agreed with the criticism concerning the use of the concept of ‘lifestyle’ and the Report should avoid the term accordingly. It was also agreed to accept the suggestion to distinguish between causal factors (environment, genetics, etc, influencing health to whatever degree) and modifying factors (prevention, treatment, access to healthcare services, influencing health to whatever degree).
INFECTIOUS DISEASES
8 A considerable number of respondents expressed profound and radical disagreement with suggestions that it could ever be acceptable for the state to interfere with the health of citizens through vaccination programmes. Quotes from these responses could be used to introduce the subject, and to explain the reasoning of the Working Party.
9 On the control of infectious diseases, many respondents commented on the importance of the role of international organisations. The observations appeared to be motivated by several reasons, which included the necessity of monitoring the global spread of diseases, and the effectiveness of controlling mechanisms. Respondents also seemed to indicate that international organisations such as the WHO were more trustworthy than national organisations, and that initiatives organised by these organisations were more acceptable. This was interesting as, ultimately, national governments would implement appropriate monitoring and control mechanisms.
10 On the two questions of whether more should be done by governments in developed countries to develop methods of preventing outbreaks of serious epidemics in other countries; and whether new measures were needed to monitor and control the spread of infectious diseases, it was noted that a full consideration of the issues raised by respondents was likely to exceed the scope of the chapter. There were a number of Reports on each of these areas by WHO, Foresight and others, and it would probably be overly ambitious for the Working Party to attempt to propose conclusions and recommendations based on a significantly shorter discussion of the complex issues underlying these questions. However, the Chapter might flag awareness of these debates, and comment in a general nature.
OBESITY
11 The respondents reflected a wide spectrum of nuanced views, most of which were already located in the current discussion in Chapter 5 of the Report. Many respondents expressed strong views about the option of withholding treatment for obese people. The discussion in the Chapter could clarify arguments about the nature of such decisions.
12 There was also discussion about whether the implications of the predicted quantitative increase of obesity had been reflected sufficiently in Chapter 5.
ALCOHOL AND SMOKING
13 Several respondents commented on the analogy suggested between the costs imposed on healthcare systems by people who drank excessive alcohol or smoked, and those who pursued adventure sports. In response the Report should clarify several important dimensions that would need to be considered in such comparisons, including the total number of people pursuing the respective activities, the fact that some activities increase, directly or indirectly, the risk of harm to others, and that, whereas adventure sports can lead to an overall health benefit, excessive consumption of alcohol or tobacco has no such benefits.
14 There was also the view that smoking tobacco and drinking alcohol (above a certain age) was legal, and that ‘therefore it is OK’. The problematic assumptions behind such assessments should be addressed in the Report. The implicit messages of banning (and not banning) certain activities could also be addressed in the section that presented the ‘intervention ladder’.
FLUORIDATION
15 Members noted the vehement opposition expressed in many responses which reiterated the range of arguments encountered during the fact finding meeting on the subject. It was agreed that it would be useful to highlight in the Report the somewhat polarised spectrum of interpretation of the York review.
ETHICS
16 While many of the comments on the questions posed in the consultation document presented interesting observations, they had little bearing on the current structure and content of Chapter 3 of the draft Report, which had developed considerably. Nonetheless, the comments pointed to several issues which should be clarified in Chapter 3. Both ‘consent’ and ‘trust’ featured in the current draft Chapter, and the question whether both of these were ‘principles’ should be considered. In any case, the importance of trust should be emphasised in the Policy Chapter, and/or the section concerning risk and evidence. In complex societies, and when dealing with complex issues, trust was crucial. Its non-coercive character was also important.
DISCUSSION OF DRAFT REPORT
Chapter 3 and 8 - Ethics
17 Chapter 3 had been reorganised and redrafted substantially in parts, to illustrate more clearly the ‘liberal proposal’ and the following liberal framework. Several points which had been discussed by email between members and the Secretariat were then summarised, concerning the issue of at which substantive or procedural points libertarians and collectivists would ‘depart’ from the liberal middle position outlined in the introduction; the need to address non-coercive ways of changing behaviour in relation to Mill’s harm principle; the relationship of this principle to the utilitarian theory in which it was embedded; and the question of extending the list of principles, and clarifying the criteria for selection.
CHAPTER 9 - POLICY
18 The policy chapter would draw on the discussion of the case studies and the two ethics Chapters. It would clarify that the audiences for the Report were policy makers, professionals and lay people. The Chapter would focus on the ‘ladder of interventions’ that could be proposed for the different case studies and was likely to vary in degrees of acceptability depending on, among other things, the quality of the evidence base, the intrusiveness of the intervention, and the level of risk or harm.
19 Members then considered a range of further issues that could be addressed in the policy chapter, including a clarification of the different types of disagreement that existed on public health policies and ways of reconciling these; the question of how non-health-agencies (that dealt with, for example, housing or urban planning) would fit in the proposed outline; and a more detailed explorations of the role and use of evidence.
PEER REVIEW
20 Members reviewed the arrangements for peer review and agreed an initial range of experts with different backgrounds who might be invited to review the draft Report. The draft list would be circulated to the full Working Party by email, with a request for further suggestions. A final list would then be re-circulated to the Working Party, and also to the Council, who would need to approve it.
ANY OTHER BUSINESS
21 It was agreed to review the structure of Chapter 2, and to move the sections that related to specific case studies into the respective chapters.
Last Updated Fri, 16 March 2007