Nuffield Council on Bioethics / Home

PRESENT
Professor Sir John Krebs FRS (Chair)
Dr Raghib Ali
Professor Tom Baldwin
Professor Christine Godfrey
Professor Trisha Greenhalgh OBE
Professor Anne Johnson FmedSci
Professor Sally Macintyre OBE FRSE CBE
Ms Julia Unwin OBE CBE

APOLOGIES
Professor Roger Brownsword, Professor Sir Kenneth Calman KCB FRCS DL FRSE, Professor Jonathan Montgomery

SECRETARIAT
Dr Catherine Moody, Mr Harald Schmidt, Ms Catherine Joynson, Ms Caroline Rogers, Ms Julia Trusler

INTRODUCTION BY THE CHAIR
1 The Chair welcomed the members of the Working Party and noted that Mr Hugh Whittall had been appointed as the new Director of the Council. He would start on 1 February and would join the Working Party at the March meeting. The focus of the meeting would be on considering the comments by the Council and on agreeing which revisions were required before peer review. The final session would aim to review and consolidate the overarching and cross cutting issues to be addressed in the last chapter of the Report.

MINUTES OF THE SIXTH MEETING OF THE WORKING PARTY
2 The minutes were approved.

DISCUSSION OF REVISED DRAFT REPORT
Chapter 2 – Ethics
3 Professor Tom Baldwin commented on recent revisions in Chapter 2 and also addressed relevant comments from members of the Council. Members agreed to expand the discussion of equality (and inequality), to clarify the notion of harm that would then be used throughout the report; to review the usefulness of considering personal responsibility in relation to rationing; and to clarify the discussion or responsibilities of individuals vis a vis (corporate) organisations.

4 The fact that the concept of ‘choices’ was problematic would be integrated in two main ways. First, text would be added to state that information was not always effective in helping people make the right choices. Secondly, drafting on the ‘provision of information’ would also be added in paragraph 2.11. It was also agreed to add an introduction to the chapter; to find a better phrase for ‘bad habits’; to clarify the concept of ‘harm’; and to move the discussion of economic issues into Chapter 3.

Chapter 3 – Policy
5 The central section describing the ‘intervention ladder’ would be revised, a new ‘lowest rung’ and a new ‘highest rung’ would be added, and examples would be given for all of the rungs.

6 In paragraph 3.17/3.18 the term ‘technocratic view’ should be replaced with a more suitable one, for example ‘the statistical view’. Concerning the question of intrusive policies, a box should be added to describe health and safety regulations, building regulations, and similar policies that considerably reduced or eliminated choice. The paragraphs on economic issues should be expanded, taking into account the material moved from Chapter 2.

Other points
7 A short section on the historical context and background of public health interventions would be re-inserted in chapter 1. The closing section of the chapter should make it clear what the report added in relation to other reports on public health issues.

Case study chapters
8 The Working Party then formed two subgroups. The Chair asked members (a) to review the chapters for consistency with the ethical framework in chapter 2; (b) to identify sections that could be deleted or shortened; (c) to review the conclusions and recommendations, and to add new ones, where appropriate. Members of the Secretariat transferred the proposed changes directly onto electronic versions of the report and/or flip charts, and revised versions of the chapters were circulated to the Working Party after the meeting. The key points were:

• Infectious diseases: the three parts of the chapter should be ‘signposted’ more clearly in the introduction; and the central points should be given more emphasis.

• Obesity: bring out more clearly the influences third parties have on people’s ‘choices’; clarify the rationing/personal responsibility issue in relation to clinical efficacy.

• Smoking and alcohol: consistency should be ensured between the section on rationing/personal responsibility in chapter 5 and 6. The issue of why smoking in the home should be seen as different from smoking in public places should be ‘unpacked’ in more detail. The chapter should also be reviewed to make clear that like-for-like comparisons were not straightforward: the harms differed between smoking and alcohol, and there was evidence for some health benefits associated with alcohol, but not with tobacco.

• Fluoridation: the chapter would be revised to take account of Professor Montgomery’s new outline.

Chapter 8 – Overarching issues
9 Members agreed that the purpose of the chapter was to draw together the discussion in the case study chapters and to identify especially salient issues. The chapter was reviewed paragraph by paragraph and it was agreed to revise the section on trust, to illustrate more clearly the range of harms and to remove the section on personal responsibility which was not really a public health issue. Duplications with Ch 3 should also be eliminated.

10 The key issues to emphasise were: that public health was about more than just collective efforts of individuals, and instead concerned the organised efforts of society; that asking for/defending highly restrictive policies must not be ‘taboo’, but that interventions must be in line with the ‘intervention ladder’, that the notion of choice was often simplistic; that there needed to be a climate of trust; that the framework was intended to help policy makers make the right decisions; that there should be consistency across different areas of public health policy.

ANY OTHER BUSINESS
11 Catherine Joynson gave a broad outline of the launch arrangements, and possible dates in November 2007 were agreed.

Last Updated Thu, 8 November 2007