PoPulationand Public HealtH etHics

A final issue returns us to the question of level of analysis. The preceding
discussion of scarcity may be regarded as unhelpful to public servants who
must allocate resources within limits dictated by superiors and (ultimately)
by Cabinet. While I am aware of this limitation, the approach taken here is
a necessary corrective to the tendency in public health ethics to leap into
the design of priority-setting algorithms without asking necessary questions
about the source and defensibility of resource constraints. * The generic issue,
in no way unique to public health, is how to act ethically as an employee in
organizations the actions and priorities of which may be ethically questionable
or indefensible — a far larger question than it is possible to address here.
Scenario shift
The first hypothetical presented in the case study sim- Continued inaction on
ply underscores the seriousness of past neglect and the the drinking water issue
urgency of committing resources to water safety. It should not be viewed in
may also reflect inadequacies in the way findings were isolation, but rather as
translated into action during the course of the study, part of a larger pattern of
indicating the need for having ‘triggers’ for action in privation that generates
research on social or environmental determinants of health disparities between
health analogous to criteria for offering treatment to Aboriginal people as a
all participants in the control or placebo arms of a clinical
trial. The possibility must be considered, however,
whole and the rest of the
Canadian population.
that a requirement for such triggers would create a disincentive to conduct
important research on determinants of health because of, for example, the
potential fiscal implications.
The second hypothetical raises more basic and complex questions. As noted
earlier, poor living conditions and health status of Aboriginal populations as
a whole, not just those living on-reserve, are a matter for grave concern. It is
not clear whether the hypothetical refers to an off-reserve community with a
high proportion of Aboriginal residents. In any event, under Canadian constitutional
arrangements, the GoC does not have primary legal authority and
responsibility, as it does in the case of on-reserve communities. (The issue of GoC
historical responsibility is too complex to address here.) Thus, outrage may well
be justified but it is not appropriately targeted at the GoC in the first instance.
* Thus, a questionnaire distributed by researchers to participants at the First Canadian
Roundtable on Public Health Ethics asked respondents to respond to this hypothetical:
“You are the Medical Officer of Health of a large health unit that must make dramatic budget
cuts. You need to decide how to cut services and programs.” 8
First Nations Drinking Water Policies
101