Minutes of the meeting held on 26 January 2006
Fri, 21 April 2006
1st 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 26 January 2006
PRESENT
Professor Sir John Krebs FRS (Chair)
Dr Raghib Ali
Professor Tom Baldwin
Professor Roger Brownsword
Professor Sir Kenneth Calman KCB FRCS DL FRSE
Professor Christine Godfrey
Professor Trisha Greenhalgh OBE
Professor Sally Macintyre OBE FRSE
Professor Jonathan Montgomery
SECRETARIAT
Dr Catherine Moody, Mr Harald Schmidt, Ms Julia Trusler, Ms Caroline Rogers
APOLOGIES
Professor Sandy Thomas, Ms Catherine Joynson
INTRODUCTION BY THE CHAIR
1 The Chair welcomed the Working Party to the first meeting and drew attention to the revised agenda which had been tabled. It was agreed to discuss items in that order, beginning with formal matters and then proceeding to a discussion of the content and focus of the report which the Working Party would produce.
TERMS OF REFERENCE
2 Members considered the draft terms of reference. After discussion it was agreed to make several revisions to enable the Working Party to consider a wider range of ethical tensions that merely those that may arise from seeking to balance individual autonomy and community benefit. It was agreed that the terms of reference should be understood primarily as enabling, rather than restricting, and a several further suggestions were made concerning the precise wording of individual terms, to reflect this agreement. The Secretariat would circulate a revised version by email before circulating the final draft for approval to the Council.
TIMETABLE, METHOD OR WORKING, FACT FINDING MEETINGS
General procedures
3 The Chairman drew attention to the information provided in the meeting papers on the number of meetings scheduled for the Working Party, and the proposed procedure for circulating minutes and papers, and keeping the Council informed of work progress.
Fact finding meetings
4 The nature and purpose of fact finding meetings was explained, where members invited external experts to discuss specific issues of relevance to the Working Party’s deliberations. Members briefly considered possible invitees, but agreed that it was too soon to identify a list possible experts who should be approached. The matter was deferred to the next meeting.
PUBLIC CONSULTATION
5 Members considered several proposals for consultation related-activities, and possible dates for holding the consultation. Professor Sir Kenneth Calman introduced the activities of the Council’s sub-group on Reaching Out to Young People, and the proposal to carry out a collaborative project with a company that specialised in organising debate events for school children. It was agreed to review these initiatives after a first draft of the consultation document had be considered at the next meeting.
6 Members also discussed the methodology employed to analyse the responses, and the way these would be used in the report. The Secretariat commented on previous practice and the Working Party agreed that it would be useful if Professor Trisha Greenhalgh would review the methodology to ensure that it was suitable for this Working Party.
BACKGROUND TO THE STUDY AND CONSIDERATION OF THE MAIN AREAS FOR DISCUSSION
7 The Chairman invited Professor Sir Kenneth Calman, Professor Tom Baldwin and Professor Jonathan Montgomery to open the discussion by commenting on the Council’s Workshop on public health issues which they had attended in 2004. Members then identified a number of overarching issues.
Concept and definition of public health
8 There were several concepts of ‘public health’ and ‘health’. It would be useful if the Working Party would comment on the variation and develop their own working definition, for example in the introduction of the report. This section could also comment on what most members of the public understood by the term, and highlight that public health issues were not merely academic, but had pragmatic relevance.
9 The health of people was influenced by several factors. These included:
(a) Genetics
(b) Socio-economics
(c) Lifestyle
(d) Environment
(e) Health-services
10 It was proposed that the Working Party should focus on (c)-(e), and be less concerned with (a) and (b). While most members agreed that this emphasis was useful, they also noted that the importance of (b) could not be ignored. It would be simplistic to reduce public health issues to a conflict simply between individual choice and community benefit. Consideration was given to the wide range of socio-political improvements, extending from improved sanitation and housing, to benefits arising from medical advances, such as vaccinations or linkage of health data and genetic information in large databases. A brief description of historical developments, and socio-economic factors affecting public health, should be included in the Report, perhaps as a short chapter following the introduction.
Role of governments and democratic processes
11 It would be interesting to examine the role of governments. Many people seemed to take the view that it was the duty of governments to protect citizens from harm. Some people went on to conclude that, for example, those substances that were not prohibited by law were not ‘really’ harmful to people.
12 In many cases governments or local authorities carry out consultations in order to assess whether measures such as fluoridation of drinking water should be carried out. To what extent could such initiatives legitimise restrictions of choice for wider populations? Which criteria would need to be met to ensure the best possible process?
Informed choice
13 The concept of informed choice required scrutiny: Was it really feasible? Which criteria need to be met for choice to be genuinely ‘informed’?
Ways of influencing behaviour
14 When is it acceptable to use indirect encouragements such as requiring evidence of vaccinations in order to attend school? Which degrees of coercion are acceptable or tolerable in the control of infectious diseases?
Discussion about Case Studies
15 Members considered the range of case studies provided in the footnote of the initial draft terms of reference and agreed that it would not be desirable to address all these areas in the Report. In the discussion, a number of points were made for, and against, inclusion of specific case studies. Members agreed to address five case studies that differed in factors such as the types of conflicts they gave rise to, the measures available to influence public health, and the success to date in doing so. For example, infectious diseases could be seen as a paradigm illustration of the free-rider problem while smoking and alcohol might make for interesting comparisons because of differences in the way governments responded in protecting public health. Members then agreed to the following initial draft structure of the Report:
Chapter 1: Introduction
Chapter 2: Socio-economic factors influencing public health
Chapter 3: Ethical framework
Chapter 4: Case Study 1: Infectious diseases
Chapter 5: Case Study 2: Obesity
Chapter 6: Case Study 3: Smoking and Alcohol
Chapter 7: Case Study 4: Enhancement/supplementation…
Chapter 8: Policy
Chapter 9: Conclusions and Recommendations
Membership
16 The Working Party considered comments from the Council and, after discussion, agreed that the Working Party might benefit more from an additional member with expertise in infectious diseases or vaccinations. It was suggested to invite a suitable expert in discussion with the Chair of the Working Party and the Council.
DRAFT PRESS ANNOUNCEMENT
17 The press release would be redrafted to take account of the results of the meeting and a new draft would be circulated by email in due course.
ANY OTHER BUSINESS
18 The Chair reminded members to return their completed forms for the Register of Interests as soon as possible to the Secretariat. Members were also invited to review tabled administrative papers.
Last Updated Fri, 21 April 2006