PoPulationand Public HealtH etHics

Within this set of process questions are sub-questions about the role that evidence
should play in the decision process. Again, implicit in the questions is
a strong commitment on the part of the authors to making decisions based
on good evidence.
Both of the above sets of questions are philosophical in that they are open to
a wide variety of answers and invite discussion about the appropriate values
that should underpin them.
The case study also raises a third set of questions that concern the specific
“Quit and Win” intervention strategy. For example they ask “Would we make
a different decision if the research showed that participants were more like
those in the target area (more the ‘at-risk population’)?” Such questions ask for
a more calculated analysis about how well this specific intervention achieves
certain goals and how the intervention might be altered to do so better.
The importance of all three types of problems underscores the need to specify
what questions have to be answered in the scenario, to prioritize which of these
will be addressed first, and to have a plan for systematically tackling each.
The reasons for taking time to identify and prioritize questions have to do
with efficiency and effectiveness. The systematic analysis of an issue requires
time and care. The type of question we choose will determine the type of
answer we get: a substantive question (what is the best decision?) will yield
a substantive answer; a process question (how should we decide?) will yield
a process answer; a question about a specific solution (what do we think of
this particular option?) will yield an answer only about that solution. If we
aren’t clear at the beginning of an analysis about the problem on which we’re
trying to make headway, we risk having a very broad conversation about a
wide range of issues without making progress on any of them.
Notice also that there are different values at stake in the different sets of questions.
Developing an ethically justified response to any of the above questions
will involve identifying, prioritizing and balancing these values. If we don’t
separate out and focus on one question at a time, we will end up trying to
compare value commitments that don’t necessarily relate to each other. For
example, if we are trying to determine what decision criteria we should use
to slice a pie, but haven’t talked about how this decision should be made, we
Use of evidence for program decision making
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