PoPulationand Public HealtH etHics

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policy Core issue Case study authors identify the central issue in choosing among the identified policy options as one of justice in the allocation of resources. The view of justice as “requir[ing] a decision-maker to weigh the competing interests of communities with known and unknown water system risks against each other, while also considering the financial implications of each option” is too narrowly focused and may mis-specify the level of analysis required. The dice are loaded as it were, in favour of accepting the proposition that “with limited funding, communities would have to be prioritized” for post-survey responses. But why must such communities compete against one another for available resources, rather than with others among the myriad expenditure objectives of the GoC? In the context of resource-allocation decisions with life-or-death consequences, it is useful to consider the view of resource scarcities provided in Calabresi and Bobbitt’s remarkable book Tragic Choices. Such scarcities are seldom natural or absolute, in the sense exemplified by shortages of compatible donor organs for transplantation or (in a hypothetical example) of a geologically rare mineral that cannot be synthesized and has no substitute in the manufacture of a life-saving medical device. Far more common are situations in which “scarcity is not the result of any absolute lack of a resource but rather of the decision by society that it is not prepared to forgo other goods and benefits in a number sufficient to remove the scarcity.” 4 Arguably, the core issue here is the (continuing) refusal of the GoC, and perhaps the society whose values it can be said to represent, to remove the scarcity in question. Assertions of resource scarcity must be assessed in the context of estimates provided by the survey authors 5 of the costs of meeting official “protocols for safe water and wastewater.” The adequacy of these protocols cannot be explored here, but they provide a useful starting point for estimating costs. The survey authors estimated the one-time costs of meeting these protocols as $1.212 billion, including capital costs, non-construction costs, and repairs to existing facilities; they estimated annual operating costs as $18.7 million. 5(p.30) A much higher cost was attached to meeting future servicing needs over the next 10 years: $4.7 billion, plus $419 million per year for operating and maintenance. 5(p.34) Considerable imprecision is involved in all such estimates, but they provide at least an order-of-magnitude indication of the amounts involved, which must be compared with total federal program spending PoPulation anD Public HealtH etHics 98
of $239.6 billion the 2010–11 fiscal year. In the absence of a credible claim related to the scarcity of any absolute lack of a resource needed to address the water safety issue, it could be held that the central issue is the ethical strength of the claim of First Nations communities to the provision of safe drinking water at a specified standard, and of the associated claim on public resources necessary to realize that objective, relative to other claims on public resources, some of which do not necessarily have any ethical force or merit. This issue exists independently of whether the risks are currently known or unknown, but the GoC’s obligations in this regard imply a prior or corollary obligation to take all reasonable measures to discover and inform about those risks through testing and disclosure of results; the Auditor-General’s 2011 report concluded that Health Canada’s progress in this area had been unsatisfactory since 2005, 1 and the survey that is the basis of the case study did not address this concern adequately as it assessed only system management and not actual water quality. Proposed resolution It is difficult to justify either the decision to defer action pending completion of the survey, given the known risks to health in some communities, or the decision to target just 72 water systems (of the much larger number that were characterized as high or medium risk) for investment over the coming five years. The difficulty is compounded by the past history of neglect of onreserve living conditions, and the fact that considerable information about the extent of the hazards to health was available well before the completion of the survey in question. The preferred course of action from a public health ethics perspective would be the third one of immediately addressing known problems while simultaneously conducting the survey. If health equity is specifically identified as a value of importance, the case for this course of action is further strengthened. In any event, an independent obligation exists to be absolutely honest and transparent with affected communities before, during and after the study (as per “questions to consider” 2 and 4). * Although costs are never irrelevant, the ethical basis for “considering the financial implications of each option” as part of the choice is unclear. * This requirement can be derived independently from several foundations, including the intrinsic value of truth-telling and the principle of respect for autonomy, which normally requires providing full information and avoiding deception (e.g, in research ethics). First Nations Drinking Water Policies 99
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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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Page 50 and 51: esearch Proposed resolution Enablin
Page 52 and 53: a tool For etHical analysis oF Publ
Page 54 and 55: esearch are explicit. In Quebec, su
Page 56 and 57: esearch reFerences 1 Bayer, R. and
Page 58 and 59: Part two Policy
Page 60 and 61: policy being increasingly introduce
Page 62 and 63: policy behaviour. Therefore, the et
Page 64 and 65: policy 18 Chapman, S. and Freeman,
Page 66 and 67: policy through outdoor smoking, any
Page 68 and 69: policy that this is an injustice. W
Page 70 and 71: DeFerring blooD Donation FroM Men w
Page 72 and 73: policy 26 per cent of new infection
Page 74 and 75: policy 6 NHS Blood and Transplant.
Page 76 and 77: policy public trust might also incl
Page 78 and 79: policy lived in certain regions in
Page 80 and 81: policy 4 Zou, S., Musavi, F., Notar
Page 82 and 83: policy Case description For nearly
Page 84 and 85: policy 3 Economic conditions could
Page 86 and 87: policy essential to examine the his
Page 88 and 89: policy lMICs. Evidence-based introd
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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 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 136 and 137: practice Questions for discussion 1
Page 138 and 139: practice In what follows, I will de
Page 140 and 141: practice will end up having to comp
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
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practice Case discussion in respons
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practice principle should only be t
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practice potentially cause the gene
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practice Nations’ constitutional
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practice Questions for discussion 1
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practice sanitation and poor housin
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practice Decision making While the
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alberta oil sanDs A toxic mixture o
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practice resolution calling for the
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practice Second, the process of oil
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practice contributing to “contrac
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practice How might the decision and
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wHose role is it to Deal witH socie
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practice same artisanal miners to d
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practice The ethical principle of b
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practice Identify the options avail
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