PoPulationand Public HealtH etHics

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practice Case discussion in response to HealtH inequities in First nations coMMunities anD canaDa’s resPonse to tHe H1n1 inFluenza PanDeMic Nicholas B. King, Ph.D. Biomedical Ethics Unit, Department of Social Studies of Medicine, Department of Epidemiology, Biostatistics, and Occupational Health, McGill University Montreal QC nICHolas.kIng@MCgIll.Ca Justice and health equity It is clear from this case narrative that living conditions and health outcomes among Canada’s First Nations communities are less than ideal. However, are these conditions unjust? Answering this question leads us to consider three theories of justice that are particularly influential in the public health arena: liberalism, egalitarianism, and utilitarianism. One answer to this question, rooted in the philosophical doctrine of liberalism, requires us to determine whether the conditions violate some basic human right. Modern liberalism holds that (1) all human beings have a fundamental right to develop and implement their own decisions about how to live their lives, free from impediments; and (2) the state thus has an obligation to ensure access to the resources that every individual requires to carry out his or her life plans. 1 It is worth noting that, from a liberal point of view, these rights hold regardless of whether their contravention has a measurable impact on health or welfare. The case narrative notes that several international organizations and agreements designate access to safe drinking water, adequate sanitation and housing as fundamental human rights. Beyond this, it is widely recognized PoPulation anD Public HealtH etHics 158
that freedom from preventable diseases, such as many infections and waterborne illnesses, is a requirement for normal human functioning, and thus is a fundamental human right. From the point of view of liberalism, then, lack of access to clean running water, basic sanitation and adequate housing is unjust, because it constitutes a violation of fundamental human rights, regardless of its impact on H1N1 morbidity or mortality. A second answer to the original question, rooted in the philosophical doctrine of egalitarianism, requires us to determine whether these conditions represent an inequitable distribution of resources and/or outcomes. Three factors are important in making this decision. First, we must agree that the currency of justice — that is, the thing being distributed — is important enough to be of concern. Most would agree, for example, that access to a life-saving medical treatment meets this criterion, while access to red jelly beans does not. Second, we must determine whether the unequal distribution of a resource or outcome among particular populations is of concern. For example, unequal distribution of transplanted organs by socio-economic status may be considered unacceptable, while unequal distribution by age or underlying health status may not. Finally, we must determine whether the cause of an unequal distribution is relevant and, if so, whether it warrants intervention. For example, men generally have lower life expectancy than women. Some argue that this inequality is due primarily to genetic or physiologic differences, so it is unavoidable and thus cannot be seen as unjust. Others argue that this inequality is due to social factors such as increased pressure on males to engage in risky behaviors, so it is avoidable and thus unjust. Most egalitarians would likely consider the inequalities described in the case narrative to be unjust. The currency of justice in this case — safe drinking water, adequate sanitation and housing — is widely considered to be a fundamental human right, so it is clearly important enough to warrant consideration. The inequality in this case puts First Nations communities at a disadvantage relative to other ethnic groups and the overall Canadian population. As this inequality further disadvantages a population that is already subject to considerable social and economic disadvantage, it constitutes an inequity from the perspective of populations affected. 2 (We should note here that this judgment might change in the case of the first “scenario shift.”) The case of causation is somewhat more complicated, and will be addressed in detail below. For now, we can say that: (1) unsafe drinking water, inadequate Health Inequities in First Nations Communities and Canada’s Response to the H1N1 Influenza Pandemic 159
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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
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policy governments, regional develo
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First nations Drinking water Polici
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policy federal government was aware
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policy reFerences 1 Health Canada.
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policy Core issue Case study author
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policy Additional issues It may be
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policy Arguably, an exception might
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policy Case Following the pharmaceu
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policy 3 What potential harms may b
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