PoPulationand Public HealtH etHics

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practice will end up having to compare everyone should get the same size of piece with we should include whoever made the pie in making the decision. When setting out the key question, it is also important to frame questions well. For example, at one point the authors ask, “Can professionals criticize policy choices without endangering their own careers?” As posed, this is an empirical question about what is descriptively true about the landscape. There are at least two concerns with framing issues this way. First, descriptive answers about the way we currently do things do not necessarily tell us how we should do them. My sense is that the authors understand this and the question is rhetorical. The authors believe that freedom of thought and expression is an important value and they wish to explore how it can be incorporated into an analysis of the process by which such decisions are made. The second concern then is that the lack of clarity in our language enables a great deal of confusion to enter the discussion — confusion that can make deliberation about the issues perplexing and painful. More importantly, poorly articulated questions could actually thwart the effort of identifying a justified response to the issue. Getting a Shared Understanding of the Context Another central element of effective ethics analysis involves looking at the context to see whether a clear picture of the landscape emerges, where there is shared understanding and where there is not, and determining what evidence grounds the emerging picture. This directly answers one of the questions raised within the case study about whether evidence should play a role in our decision process: yes, good ethics requires good evidence, and any decision about how to allocate resources should take into account what research says about the context within which the decision is made. The reason for careful assessment of the descriptive context is that the end purpose of an ethics analysis is to bring about a state of affairs where what should matter most is brought to life. This in turn allows decision makers and the broader community they are serving to live with greater integrity. The key here is that the goal is a change — either of personal outlook and behaviour or of social arrangement in some form. In order for one to effectively make change, one needs to understand what the world currently looks like and what impact different change strategies can be expected to have. Ensuring we have the facts right is a crucial step toward ensuring we live up to our values. PoPulation anD Public HealtH etHics 140
However, the matter of facts is not so simple. First, this requires understanding how each of the parties involved in the story sees the context and exploring the reasons for their assessment. This involves tackling difficult questions like what counts as good evidence. Second, it is imperative to recognize that research and evidence alone do not tell us what we should do. Knowing that only a few people signed up for the “Quit and Win” program, the demographic they come from or that very few quit after enrolling, does not tell us whether or not to support the program. It is only against a sense of what matters that these facts take on meaning. So systematic analysis of evidence must be undertaken alongside systematic analysis of values for us to know how to move forward. Third, it is important to have a justified descriptive understanding of many areas of the context. The case study itself provides some information in four categories: tobacco use, the “Quit and Win” strategy, the decision-making context in general, and one story of how decisions were made in a particular region. A justified substantive resource-allocation decision would require more details in each of these categories. For example, if certain authorities are proponents of “Quit and Win” despite the evidence, why is this so? Do they understand the evidence differently? What is important to them such that what the evidence shows is less relevant? Because resource allocation is a relative concern — that is, it calls for weighing the benefit of competing options — what are the other options and what are the benefits that these would bring? In addition, we will need information about areas that go beyond what have been formally studied using traditional research methods. For instance, we also need to understand the values and beliefs about the target population and the meaning of the targeted behavior in their lives. Good ethics analysis requires an expansive understanding of the descriptive landscape.* This involves identification of the relevant categories of information, good data within each of these categories, and conversation among affected parties. * This should not be interpreted to mean that we can’t have good ethics analysis without excellent evidence and shared understanding of the facts. Decisions of course have to be made in a timely manner. The point here is that we have to do the best we can at understanding the descriptive landscape given the resources we have, recognizing that the quality of an ethics analysis will in part be proportional to the quality of evidence available. Use of evidence for program decision making 141
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PoPulationand Public HealtH etHics
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contents Acknowledgements - page 5
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acknowleDgeMents The Partners would
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» Create a tool to support instruc
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Each of the discussants took on thi
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Twenty years on, things have change
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intervention (say reduction in mort
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ethics understands dilemmas not onl
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priority setting. 17 Once more, usi
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6 See for example the WHO Commissio
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obesity surveillance in scHool cHil
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esearch 2 Inevitably children will
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esearch Case discussion in response
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It would be ideal to get active inf
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esearch participation, leading to a
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to sHare or not to sHare? Secondary
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esearch Scenario shift » What if t
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esearch Many different parties have
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esearch of his concern for people w
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esearcH etHics anD conFlicts oF int
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esearch and non-public information
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esearch reFerences 1 Public Health
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esearch Key ethical dimensions Perh
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esearch such support, seen across t
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esearch Proposed resolution Enablin
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a tool For etHical analysis oF Publ
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esearch are explicit. In Quebec, su
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esearch reFerences 1 Bayer, R. and
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Part two Policy
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policy being increasingly introduce
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policy behaviour. Therefore, the et
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policy 18 Chapman, S. and Freeman,
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policy through outdoor smoking, any
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policy that this is an injustice. W
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DeFerring blooD Donation FroM Men w
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policy 26 per cent of new infection
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policy 6 NHS Blood and Transplant.
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policy public trust might also incl
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policy lived in certain regions in
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policy 4 Zou, S., Musavi, F., Notar
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policy Case description For nearly
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policy 3 Economic conditions could
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policy essential to examine the his
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policy lMICs. Evidence-based introd
Page 90 and 91: policy governments, regional develo
Page 92 and 93: First nations Drinking water Polici
Page 94 and 95: policy federal government was aware
Page 96 and 97: policy reFerences 1 Health Canada.
Page 98 and 99: policy Core issue Case study author
Page 100 and 101: policy Additional issues It may be
Page 102 and 103: policy Arguably, an exception might
Page 104 and 105: policy Case Following the pharmaceu
Page 106 and 107: policy 3 What potential harms may b
Page 108 and 109: policy in the “anti-cancer vaccin
Page 110 and 111: policy adults may choose for themse
Page 112 and 113: policy Men also suffer some HPV-cau
Page 114 and 115: ManDatory iMMunization oF local Pub
Page 116 and 117: policy for exemptions and declinati
Page 118 and 119: policy Case discussion in response
Page 120 and 121: policy the degree of infringement o
Page 122 and 123: Part tHree Practice
Page 124 and 125: practice Case The Inquiry found tha
Page 126 and 127: practice Questions for discussion 1
Page 128 and 129: practice is a basic ethical obligat
Page 130 and 131: practice harm is remote, the cost/b
Page 132 and 133: practice that the professional plac
Page 134 and 135: practice or equitably reaching your
Page 138 and 139: practice In what follows, I will de
Page 142 and 143: practice Getting Clear on What’s
Page 144 and 145: using PersonalizeD letters oF invit
Page 146 and 147: practice Cervical cancer is relativ
Page 148 and 149: practice Case discussion in respons
Page 150 and 151: practice principle should only be t
Page 152 and 153: practice potentially cause the gene
Page 154 and 155: practice Nations’ constitutional
Page 160 and 161: practice sanitation and poor housin
Page 162 and 163: practice Decision making While the
Page 164 and 165: alberta oil sanDs A toxic mixture o
Page 166 and 167: practice resolution calling for the
Page 170 and 171: practice Second, the process of oil
Page 172 and 173: practice contributing to “contrac
Page 174 and 175: practice How might the decision and
Page 176 and 177: wHose role is it to Deal witH socie
Page 178 and 179: practice same artisanal miners to d
Page 182 and 183: practice The ethical principle of b
Page 184 and 185: practice Identify the options avail
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