Ethical Considerations in Framing and Communicating Public Health Information

1. Ethical Considerations in Framing and Communicating Public Health Information John.Coggon@Bristol.ac.uk Centre for Health, Law, and Society, @CHLSBristol Alcohol and Public Health: Framing and Communicating Risk Drug and Alcohol Research Centre, Middlesex University, 20th November, 2018 Centre for Health, Law, and Society @CHLSBristol

2. “Are there ethical dilemmas arising from the need to select and emphasise some ‘facts’ to the exclusion of others or from the way in which statistics are presented or from assumptions regarding what the public understands or ‘needs to know’?” Centre for Health, Law, and Society @CHLSBristol

3. ‘Translation’ raises questions about: • Ensuring public understanding, including: • Communicative efficacy and impact, e.g. in how a risk factor is framed • Controlling or responding to dominant narratives: for example in how, or by reference to what, different ‘stories’ about the public’s health are told Centre for Health, Law, and Society @CHLSBristol

4. ‘Translation’ raises questions about: • Ethical questions regarding communication, including: • Selectivity and points of emphasis • Proper ‘treatment’ of different publics: respectful communication; determining who needs to know what; who can understand what level of complexity; etc. • Transparency principles: how open should we be about what we are open and closed about? Centre for Health, Law, and Society @CHLSBristol

5. “Are there ethical dilemmas arising from the need to…” present certain information in certain ways? • When faced with a dilemma, either way you need to do something wrong or bad • In the face of a dilemma, acting wrongly may be justified by reference to a principle of necessity (need) But… • The ‘need’ may perhaps be established without ethical dilemma. Centre for Health, Law, and Society @CHLSBristol

6. Points to consider: • What is the mandate for action (what motivates and justifies decisions about communication)? • Whose ‘rules of engagement’ apply (and are they the same for everyone; outside, but also within, public health)? • Who controls the narrative? • Are there side constraints on the effective means of achieving public health ends? Centre for Health, Law, and Society @CHLSBristol

7. Aims and overview • Challenges for public health ethics, equity, and values • Communicative obligations and the moral mandate of public health • Look at ethical considerations in public and political engagement • Introduce practical examples with reference to FPH report on the ‘Nanny State Debate’ Centre for Health, Law, and Society @CHLSBristol

8. Part 1 Ethics, Equity, and Public Health Centre for Health, Law, and Society @CHLSBristol

9. Defining equity in health “Equity means social justice or fairness; it is an ethical concept, grounded in principles of distributive justice. Equity in health can be—and has widely been—defined as the absence of socially unjust or unfair health disparities. However, because social justice and fairness can be interpreted differently by different people in different settings, a definition is needed that can be operationalised based on measurable criteria.” Paula Braveman and Sophia Gruskin, ‘Defining Equity in Health,’ Journal of Epidemiology and Community Health (2003) 57, 254-258, p. 254. Centre for Health, Law, and Society @CHLSBristol

10. Ethics, Equality, Values ‘Three Children and a Flute’: who should get it? • Anne: the only child who can play it • Bob: has no toys, and can afford none • Carla: made the flute, through several months’ labour • A: favoured by utilitarian (though balance of good in each) • B: favoured by economic egalitarian • C: favoured by libertarian Amartya Sen, The Idea of Justice, (Penguin, 2009), pp 12-15 Centre for Health, Law, and Society @CHLSBristol

11. Two roles for Public Health Ethics? • Philosophical ethics • The academic’s question: “What makes health public?” • Public ethics • The activist’s question: “How can health be made public?” Centre for Health, Law, and Society @CHLSBristol

12. Part 2 Public Health, Communication, and the ‘Moral Mandate’ Centre for Health, Law, and Society @CHLSBristol

13. Science/Politics Duality within Public Health Public Health England’s first in its list of responsibilities: [M]aking the public healthier and reducing differences between the health of different groups by promoting healthier lifestyles, advising government and supporting action by local government, the NHS and the public[.]   UK Faculty of Public Health’s mission statement: Our overarching mission is to promote and protect the health and wellbeing of everyone in society by playing a leading role in assuring an effective public health workforce, promoting public health knowledge and advocating for the very best conditions for good health. www.gov.uk/government/organisations/public-health-england/about www.fph.org.uk/our_mission Centre for Health, Law, and Society @CHLSBristol

14. Tensions in Ethical Public Health? Tension within public health itself?: • A science: objective, neutral  epistemic authority • A basis of advocacy: agenda-setting  politically partisan A line between: • (Obligatory?) public/political engagement; and • Persuasion and undue/unethical politicking? Centre for Health, Law, and Society @CHLSBristol

15. Public Health and Social Justice • Public health is long-recognised as “the science of social justice” Richard Horton, ‘Offline: Where is public health leadership in England?’ The Lancet (2011) 378, 1060 • However: “The language of public health was rarely invoked among bioethicists [until the turn of the century]. Nonetheless, extraordinary contributions to public health ethics were made during this time, particularly in three areas of inquiry: the ethics of health promotion, resource allocation, and the civil liberties vs. public health questions precipitated by the HIV/AIDS epidemic.” Nancy Kass, ‘Public Health Ethics: From Foundations Frameworks to Justice and Global Public health,’ Journal of Law, Medicine, and Ethics (2004) 32, 232-242 Centre for Health, Law, and Society @CHLSBristol

16. Early ‘Public Health Ethics’ “If there is a characteristic ethical orientation within the field of public health today [2003], it is probably less theoretical or academic than practical and adversarial. The ethical persuasion most lively in the field is a stance of advocacy for those social goals and reforms that public health professionals believe would enhance the general health and well-being, especially of those least well off in society.” Public Health Ethics as: • Professional Ethics • Advocacy Ethics • Applied Ethics Bruce Jennings, ‘Frameworks for Ethics in Public Health,’ Acta Bioethica (2003) 9:2, 165-176 Centre for Health, Law, and Society @CHLSBristol

17. Part 3 Ethical Considerations in Public and Political Engagement Centre for Health, Law, and Society @CHLSBristol

18. Politics as medicine for the masses • Johan Mackenbach builds on Rudolf Virchow’s idea that: “Medicine is a social science, and politics nothing but medicine at a larger scale.” Rudolf Virchow, Der Armenarzt. Medicinische Reform 1848; 18: 125-7 • Mackenbach looks to the idea of a ‘modern Virchow’: • Population approach • Embrace of ‘Health in All Policies’ • Essential role perceived for law, politics, and governance Johan Mackenbach, ‘Politics is nothing but medicine at a larger scale: reflections on public health’s biggest idea,’ Journal of Epidemiology and Community Health (2009) 63:3, 181-184 Centre for Health, Law, and Society @CHLSBristol

19. Mackenbach’s problems of politics for public health • “Politics is a struggle between conflicting ideologies and interests, in which health provides only one of the many types of argument.” • “Politics operates on a timescale governed by elections and media attention, which is at odds with the greater timescale at which population health and its determinants can be expected to change. An emphatically political approach to public health may also in the long run prove to be a self-defeating strategy, because of the dangers of politicisation. Politics is divisive, and long-term support for public health can be eroded as well as strengthened by recurrent political debates.” Mackenbach, ‘Politics is nothing but medicine at a larger scale,’ p. 183 Centre for Health, Law, and Society @CHLSBristol

20. Mackenbach’s “Ladder of Political Activism” Top rung: Become a politician Third rung: Lobby and engage with politicians Second rung: Promote understanding by e.g. addressing reports to government, speaking to media, advisory committee activity Bottom rung: Be politically passive: disseminate research within the sector; only to politicians if invited Centre for Health, Law, and Society @CHLSBristol

21. Public and political engagement Contextualising range of approaches and rationales • Different professional approaches • Different forms of practical public health problems, with natural consequence for different (types of) ‘stakeholders’ • Different roles for different members of the public health community • Differences in political, social, temporal, and geographical context • Different views on what will be optimally effective Centre for Health, Law, and Society @CHLSBristol

22. Part 4 Combining Principled and Practical Concerns Centre for Health, Law, and Society @CHLSBristol

23. FPH Nanny State Report John Coggon, The Nanny State Debate: A Place Where Words Don’t Do Justice (London: Faculty of Public Health, 2018) www.fph.org.uk/media/1972/fph-nannystatedebate-report-final.pdf Centre for Health, Law, and Society @CHLSBristol

24. Challenges from Nanny State Critics • Principled arguments • Hard/soft paternalism • Slippery slopes  Question sustainability • Empirical claims • Philosophical claims • Non-principled arguments • Arbitrary/incoherent claims  Question rationale • Mistake, or hidden agenda/interest? Centre for Health, Law, and Society @CHLSBristol

25. Three examples of communication strategies 1. Deny nannying: • CfStacy M. Carter, Vikki A. Entwistle, Miles Little, ‘Relational Conceptions of Paternalism: A way to rebut nanny-state accusations and evaluate public health interventions,’ Public Health (2015) 129:8, 1021-1029 2. Take on and respond to health-harming organisations and policies: • CfMartin McKee and Pascal Diethelm, ‘How the growth of denialism undermines public health,’ BMJ 2010;341:c6950; Martin McKee and David Stuckler, ‘Revisiting the Corporate and Commercial Determinants of Health,’ American Journal of Public Health (2018) 108, 1167-1170. 3. ‘Own’ or ‘reclaim’ nannying: • Cf Simon Capewell, ‘Are Nanny States Healthier States? Yes’ BMJ 2016;355:i6341 Centre for Health, Law, and Society @CHLSBristol

26. Concluding Reflections Centre for Health, Law, and Society @CHLSBristol

27. Points to consider: • What is the mandate for action (what motivates and justifies decisions about communication)? • Whose ‘rules of engagement’ apply (and are they the same for everyone; outside, but also within, public health)? • Who controls the narrative? • Are there side constraints on the effective means of achieving public health ends? Centre for Health, Law, and Society @CHLSBristol

28. Conclusion:Aims for ethical framing of public health messages • Principled and effective: • Substantive, not merely formal, parameters; sensitivity to context and audience; no retreat to ‘everyone else is doing it…’ • Public health not just a ‘contained’ scheme of professional ethics, but related to a wholesale social ethic: • And public health is not just a science… • … it presents political imperatives • To be principled and effective, we need to understand our own and others’ arguments, not just our/their methods and motivations, in ethical terms Centre for Health, Law, and Society @CHLSBristol