Minutes of the meeting held on 26 May 2006
Wed, 6 September 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 Friday 26 May 2006
PRESENT
Professor Sir John Krebs FRS (Chair)
Professor Tom Baldwin
Professor Roger Brownsword
Professor Christine Godfrey
Professor Trisha Greenhalgh OBE
Professor Anne Johnson FMedSci
Professor Sally Macintyre OBE FRSE
Professor Jonathan Montgomery
APOLOGIES
Dr Raghib Ali
Ms Julia Unwin OBE
Professor Sir Kenneth Calman KCB FRCS DL FRSE
Professor Sandy Thomas
SECRETARIAT
Mr Harald Schmidt, Ms Catherine Joynson, Ms Julia Trusler
INTRODUCTION BY THE CHAIR AND MATTERS ARISING
1 The Chair welcomed the members of the Working Party and introduced Professor Anne Johnson, who had accepted the Council’s invitation to join the Working Party. The Working Party considered the actions points of the minutes of the second meeting.
2 The consultation had been launched on Friday 19 May, and a briefing for journalists had taken place at the Science Media Centre on 18 May. Members took note of the media activity that had been generated, and of the distribution of the document through the Secretariat. Members also reviewed progress of the collaboration with Ecsite. The project sought to stimulate discussion among school children who attended facilitated meetings at Science Centres throughout the UK, and provided a possibility for the Working Party to obtain a summary of their views. The Secretariat, advised by Dr Raghib Ali, Professor Tom Baldwin, Professor Christine Godfrey, Professor Trisha Greenhalgh and Professor Jonathan Montgomery, had commented on materials to be used by Ecsite, drawing on material of the consultation document.
3 It had been agreed to focus in the meeting on Chapter 3 (ethics) and Chapter 7 (supplementation). Members leading on other chapters would present their drafts at the next meeting, with the exception of Professor Anne Johnson’s chapter on infectious diseases, which would be considered in September.
MINUTES OF THE SECOND MEETING
4 The minutes were approved.
CHAPTER 3 - ETHICS
5 The Chair thanked Professor Baldwin for an excellent first draft of the Chapter on ethical Issues and invited him to introduce briefly the principal points. The Chapter began by considering in what sense public health might be viewed as a public good. It focused on a liberal framework as a starting point. This was relevant to any form of state, whether it was organised in a libertarian or highly paternalistic way. The Chapter then reviewed Mill’s harm principle, clarifying that in Mill’s own conception this applied only to ‘human beings in the maturity of their faculties’, and that he also highlighted cases where people might need to be protected against the consequences of their own actions and external injury. This starting point, and Mill’s emphasis on individuality (in the sense that the freedom of people to construct their own lives had crucial importance) provided the basis for a sketch of a liberal framework that was set out in more detail in paragraph 8 of the draft.
6 Several comments were made in the following discussion. Concerning the section on ‘the nature of public health’ it might be useful to differentiate between two further notions: (a) public health as relating to structural and other conditions (ie health care services and infrastructures in cities conducive to exercise) and (b) public health as a measure of the health of people, which should be maximised.
7 A useful addition to the Chapter would be an exploration of the role of third parties. At present, it focused on a conflict between the state and citizens, as described in paragraph 4 of the draft. It might also be useful to expand the focus on the state and the citizens to include non-citizens, such as illegal immigrants.
8 The case of obesity raised the question of how governments should act in the case of public health issues where solutions to achieving better health states were likely to be extremely complex. The pressure on politicians to be seen to be ‘doing something’, or to offer a ‘magic bullet’ was great, but the extent of the effectiveness of single interventions usually unclear. This issue was likely to addressed elsewhere in more detail but Chapter 3 should include some discussion about the ‘ethics of acting under uncertainty’.
9 The ‘benefit and burden’ (or: social solidarity) argument might be addressed more explicitly in the Chapter, emphasising the point that people were highly interdependent. The case study on fluoridation also illustrated the ‘loss of chance’ argument that might be flagged in Chapter 3.
10 On health inequalities, there was brief discussion about whether a more ‘modern’ liberal framework should be adopted, or parts thereof. One possible starting point might be the Rawlsian ‘maximin principle’.
CHAPTER 7 - SUPPLEMENTATION
11 Professor Jonathan Montgomery explained that rather than producing a first draft of this Chapter, it had seemed more appropriate at this stage to compile material that would help the Working Party find its stance on issues raised by fluoridation. The Chapter began by giving five possible starting points to frame the issues, ranging from the right to health, the importance of consent and choice, the question of whether fluoridation sought primarily to prevent harm or produce benefits and the role of democracy.
12 All members agreed that it would not be likely that one of these points would be chosen over all others. Rather the five starting points raised distinct nuances that should all be spelled out in the Chapter. One way of doing this might be to insert boxes that presented short case studies to illustrate specific points.
13 A number of further points were made. One related to the question of what should be the default position of the state. According to a line of thought that has some prominence in legal philosophy in the US, the state should be committed to ensuring citizens were able to exercise ‘choice’. But did that mean that only an ‘opt-in’ solution would be acceptable in the case of fluoridation? Why should the opposite case not be acceptable as the default, so that people could exercise choice by ‘opting out’? Reasons underlying the different options should be addressed.
14 Comparisons to other areas of supplementation should be made, and it should be clarified whether (re-)fortification of flour was mandatory by law, and whether it was practically impossible to buy non-fortified flour in the UK. Overall, a central question that the Chapter should discuss was whether the primary task of the state was to provide healthy or safe food and water, or both. Arguments for and against these options, taking into account the implications raised by the technical and other aspects of the different types of enrichments should be considered.
ANY OTHER BUSINESS
15 The Secretariat would contact the members of the Working Party in the near future to identify suitable dates for meetings in 2007.
Last Updated Fri, 15 December 2006