Minutes of the meeting held on 28 March 2006
Tue, 18 July 2006
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 28 March 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
Professor Sandy Thomas, Mr Harald Schmidt, Ms Catherine Joynson, Ms Julia Trusler, Ms Caroline Rogers
APOLOGIES
Ms Julia Unwin OBE
INTRODUCTION BY THE CHAIR AND MATTERS ARISING
1 The Chair welcomed the members of the Working Party. A brief discussion about membership followed.
MINUTES OF THE FIRST MEETING
2 The minutes were approved.
WIDER CONSULTATION
3 The Chair proposed that the main focus of the meeting should be on the wider consultation. It would be useful to consider the draft document in detail in order to agree revisions for a final version and to agree on the timing of the consultation period. Members agreed and reviewed the document section by section. General comments and points of importance for the corresponding sections of the draft Report are summarised below.
General comments
4 All references provided should be reviewed to ensure that, wherever possible, authoritative and peer-reviewed literature was given as sources. Where this was not possible, adequate qualifications should be provided.
5 Statistical information should be reviewed to ensure that the document was not overly biased towards data for England. Wherever possible, UK-wide figures should be provided. In general, it would be useful to refer to the UK throughout the document as far as possible. However in some instances there were different methods of collecting and analysing data in England, Scotland and Wales. Providing this information and explaining the differences might confuse readers, rather than illuminate the points being made. It was agreed that the available data should be reviewed on a case by case basis. The issue should in any case also be considered early on in the drafting of the case study chapters in the Report.
Background and policy context
6 There was some discussion about the usefulness of the term ‘factors’ in describing which influences there were on public health. It was agreed to review the section and to clarify (a) that there were no clear cut distinctions between them, as there was considerable overlap and sometimes complex interaction between factors, and (b) that what were described as factors could have positive as well as negative influences on public health.
Ways of influencing public health
7 The bullet points listing factors that influenced the effectiveness of public health interventions should include reference to whether or not risk was perceived to be under personal control. Professor Sir Ken Calman would review the last bullet to ensure that it made the point that acceptability of new measures was influenced by the degree of trust which the public had in scientists and the government.
8 The introduction to the list stating types of interventions should be reviewed. It should be added that there were a number of different agents who could make use of these measures, ranging from the government to companies, to the media, to grass roots movements.
Obesity
9 The case study should give more emphasis to the importance of exercise to illustrate that growing rates of obesity are not simply a result of excessive eating. Reference should be made to statistics that showed that over past decades, the energy intake of individuals had actually decreased, and that obesity was influenced to a considerable degree by decreased levels of energy expenditure through physical exercise.
Alcohol
10 The section should be revised to state that whereas awareness of the risks of smoking was relatively widespread, this did not seem to be the case for alcohol, where more ‘mixed messages’ could be found. Dr Ragib Ali would review the section and also provide a reference for the statement that the burden of disease of alcohol is of a similar magnitude as smoking.
11 A question should be added that asked what the responsibilities were of the range of parties involved, as it could be argued that these differed in individual cases, for example, for producers and retailers of alcohol.
Fluoridation of water
12 More detail should be added on other cases where supplements were routinely provided. The section should be reviewed again to ensure that two central points were made clearly: (a) that the benefits of fluoridation could only be achieved by reducing choice, and (b) that most concerns appeared to result from fears about being ‘mass-medicated’. The special situation of children should also be explicitly acknowledged. It could be argued that there was an obligation to provide for their best possible future, and this might require fluoridation, especially if it could be shown that children who benefited most were those of less well off families, who might be unlikely to receive other forms of supplements. A question relating to this situation should be included and Professor Jonathan Montgomery would review the revised section.
Ethics
13 Members reviewed the proposed section on ethical concepts. It was important to be aware of a difference in function between the chapter on ethics in the Report, and the ethics section in the consultation document. The former would need to help people think through the ethical issues, and in addition would need to support the conclusions and recommendations of the Working Party. By contrast, the primary function of the section in the consultation paper was to help people frame the ethical questions which they see as relevant. This point should be considered in any revision made to the section in the consultation document.
14 Several options were proposed to simplify the ethics section in the consultation document. One model might be to start from a main axis with only two poles: at one end there was the ‘individualism’ at the other ‘stateism’. This spectrum could help to illustrate differences between the ‘minimal state’ and the comprehensive ‘welfare state’. Concepts such as ‘the duty to care’ or ‘responsibility for vulnerable subgroups’ could then be used to address which agents (government, NGOs, industry, communities, families, etc) had which responsibilities along the spectrum.
15 The concepts of consent, trust, and paternalism were discussed. The point was that many of those who were opposed to measures such as fluoridation based their objection on concerns that these interventions were paternalistic. However, it was not straightforward to claim that the opposite position was completely non-paternalistic: in either case a judgement was made about the choices people were able to make. It would therefore be useful to clarify that the default position is never truly ‘neutral’.
Consultation document - next steps
16 The Secretariat would revise the consultation document in the light of the comments by the Working Party and would re-circulate the next version after Easter. The document would also be reviewed by the Council. The launch could take place in early/mid May. Relevant dates would be circulated to the Working Party by email.
17 Members were invited to participate in the Ecsite project, which sought to stimulate discussion among school children and might provide the Working Party with a summary of their views. Depending on the timing of the consultation and Ecsite’s workshops, these results might be available at the same time as the consultation responses. Dr Raghib Ali, Professor Tom Baldwin, Professor Christine Godfrey, Professor Trisha Greenhalgh and Professor Jonathan Montgomery expressed an interest to get involved in the collaboration with Ecsite.
DRAFT REPORT
18 The Chair thanked Professor Sir Kenneth Calman, and Professor Sally Macintyre for their contributions to the draft Report, which were, respectively, included in the current draft and tabled for the meeting. Professor Sir John Krebs had also contributed drafting on the obesity case study, which had been included in the draft Report. While there was insufficient time to consider these drafts, members agreed that the discussion of the consultation document had been most useful in shaping important elements of the approach that should be taken in the Report.
19 For the next meeting, Professor Tom Baldwin and Professor Roger Brownsword would develop a first draft of the ethics chapter. Professor Jonathan Montgomery would develop the case study on enhancement of food and water into a first draft of a complete chapter.
FACT FINDING MEETINGS
20 For the next meeting in May, experts on obesity should be invited, and the Secretariat should identify suitable invitees.
Last Updated Tue, 18 July 2006