Population and Public Health Ethics in Canada: a snapshot of current national initiatives and future issues.

Viehbeck, Sarah M. ; Melnychuk, Ryan ; McDougall, Christopher W. 等

Reducing health inequities is...an ethical imperative. Social injustice is killing people on a grand scale". This quote, from the final report of the WHO Commission on Social Determinants of Health (p. 26), suggests the central role that ethics can and should play in the resource allocation, design, implementation and evaluation of upstream population health interventions aimed at the social, cultural, environmental and structural determinants of health. (1) Beyond merely identifying the need to intervene or not, the linked fields of population and public health (PPH) are replete with ethical issues, which span research, policy, and practice. While bioethics provides a foundation for health care professionals to "identify and respond to moral dilemmas" in their practice, (2) PPH ethics addresses critical issues related to the tensions between individual and collective approaches. (3) Some core principles for PPH ethics have been advanced, (4-7) including concepts such as relational personhood and relational solidarity, (4) reciprocity, (5) equity and justice, (6) and the distribution of health and risk. (7) However, practical guidance and tools to support the application of these principles to the design and evaluation of PPH interventions and to moral dilemmas, which arise in programs and practice with few exceptions--such as pandemic preparedness and response--are limited. For example, how are choices made among competing intervention options, weighing the potential for longterm and more equitable, population-level benefits against more immediate, individually-oriented benefits that are experienced only by more advantaged populations? There remains a need to build capacity for applying a PPH ethics approach among researchers, managers, practitioners, and those responsible for resource distribution.

This paper presents the approach to building capacity for PPH ethics by three national-level organizations: the Canadian Institutes of Health Research-Institute of Population and Public Health (CIHR IPPH), the National Collaborating Centre for Healthy Public Policy (NCCHPP) and the Public Health Agency of Canada (PHAC). By first looking at each of the organizations' respective activities and then comparing these efforts across organizations, we synthesize our common approaches and highlight future directions. We pose questions aimed at stimulating dialogue about the role of, and challenges confronting, the emerging field of PPH ethics in Canada.

Canadian Institutes of Health Research--Institute of Population and Public Health

The 2009-2014 strategic plan of the Canadian Institutes of Health Research--Institute of Population and Public Health (CIHR-IPPH) (8) prioritizes the reduction of avoidable and unjust health disparities and is deliberately infused with the principles of equity. The Institute recognizes the normative judgement involved in describing systematic differences in health as inequitable, the important linkage to social justice, and the moral imperative to address health inequities as ensconced in Human Rights Codes. (9) The Institute's work complements and extends, in a substantive way for PPH, the work of the CIHR Ethics Office with which the Institute collaborates.

Within the Institute's vision for health equity, fostering and refining the development of ethical frameworks for population health interventions in Canada and globally is a strategic objective. (8) The Institute is actively promoting a PPH ethics agenda as an integral component of evaluating population health interventions and their scale-up. CIHR-IPPH aims to: 1) stimulate discussion, debate and innovation regarding the values and principles underlying PPH interventions from within and beyond the health sector; and 2) develop framework(s) to make these values and principles explicit and to help guide research and practice.

As a research funder, CIHR-IPPH has supported ethics-relevant research through funding opportunities. A recent example includes rapid response funding (in partnership with PHAC, the CIHR Ethics Office, and other CIHR Institutes) for health systems, ethics and knowledge translation research on the implications of the H1N1 pandemic and its impact on vulnerable populations. This funding opportunity was designed to encourage research on the potential ethical, legal and social implications of public health and other health care system interventions related to H1N1.

To complement research funding for PPH ethics, CIHR-IPPH released an annotated bibliography in November 2009 of selected works relevant to population health ethics in order to begin a dialogue and provide a sense of the scope, issues and debates in the field. (10) IPPH has also hosted two initiatives aimed at considering and developing key principles and frameworks for population health interventions. (11) Both used distance education technology to virtually engage a pan-Canadian group of approximately 30 researchers, trainees, policy-makers and practitioners. The first of these activities, a Journal Club, was held over six sessions from February-May 2010 and featured presentations and group discussion led by some of the authors whose work was featured in the annotated bibliography. To advance discussions from the Journal Club, IPPH hosted a virtual Debate and Dialogue Series over six sessions from October 2010-May 2011. This Series focused on further developing population health ethics principles by applying them in the discussion and analysis of specific cases such as food security interventions and policies related to smoking in cars where children are present. Looking ahead, the Institute will be working to integrate ethics into knowledge translation approaches and encouraging funded researchers and teams to share their cumulative learning on PPH ethics.

Public Health Agency of Canada

The approach to PPH ethics at the Public Health Agency of Canada (PHAC) is rooted in the six core functions of public health articulated in the Naylor Report on SARS: (12) health protection, health surveillance, disease and injury prevention, population health assessment, health promotion and disaster response. Recognizing that successful PPH interventions often transcend the boundaries of any singular core function, and that these boundaries are themselves very fluid, PPH is a fundamentally interdependent and interdisciplinary endeavour. Successes are more readily achievable when open communication and trust exist between those working within different core functions. PPH ethics then, with its population focus, is the moderator of that interdisciplinary space, a broker that facilitates dialogue and discussion on ethical issues and challenges in PPH, while differentiating PPH ethics from contemporary bioethics and medical ethics through an elucidation of the core tensions in PPH: tensions between the individual and the population; the population and the state; and the state and the individual. (13)

First established in 2006, the Office of Public Health Practice's (OPHP) Public Health Law and Ethics Program (PHLEP) is composed of the three interrelated streams of public health law, research ethics and public health ethics. The first major PPH ethics initiative led by PHLEP was the organization of the successful 2007 First Canadian Roundtable on Public Health Ethics. (14) The primary focus of the public health ethics stream of PHLEP is threefold: the continued integration of PPH ethics in the practice of public health at PHAC and throughout Canada; ethics policy and advisory functions for PHAC; and collaborations. Within PHAC, PHLEP provides training and development opportunities in PPH ethics to public health practitioners including public health field staff, epidemiologists and quarantine officers. Training and development activities include lectures, interactive discussions on PPH ethics and casebased learning sessions driven by ethical issues and challenges arising in PPH practice. PHLEP also works with provincial/territorial/ municipal public health units or regional health authorities, academia, other federal government departments, and nongovernmental organizations to support and promote ethics dialogues among public health practitioners across Canada. The ethics policy and advisory functions represent internal PHAC mechanisms to provide PPH policy input through a public health ethics lens, as well as to provide ethics advice and recommendations to PHAC programs. In response to the 2009-10 H1N1 influenza pandemic, a Chief Public Health Officer's (CPHO) Ethics Advisory Committee (EAC) was created to advise the CPHO on ethical issues and questions related to PHAC programs, research and services, and issues of national significance to the practice of public health in Canada. The collaboration function includes the development and dissemination of learning and educational materials, collaborations with researchers engaged in research on public health ethics, the development of policies and guidelines in conjunction with other federal government departments, and promoting knowledge translation and exchanges between those conducting research in PPH ethics and public health practitioners and decision-makers.

National Collaborating Centre for Healthy Public Policy

In 2010, the National Collaborating Centre for Healthy Public Policy (NCCHPP) embarked on a five-year project to: 1) identify and connect individuals and organizations engaged in PPH ethics issues by building and reinforcing links among practitioners, researchers, policy-makers and educators; 2) increase awareness of new and foundational work in PPH ethics, as well as identify research opportunities, through the synthesis and application of conceptual and empirical knowledge in the field; and 3) produce tools that enable PPH actors to better understand the diverse policy processes with impacts on population health, such that those actors are better equipped to meaningfully contribute to development and implementation of healthy public policies.

The NCCHPP has produced documents, training modules tailored for different professional groups in Canada, and resource collections to support the integration of PPH ethics tools into decision-making and policy across the country. These include a List of Public Health Ethics Researchers and Instructors across Canada; (15) a collection of Case Studies of Ethics During a Pandemic; (16) the proceedings and presentations from numerous consultations, workshops and other learning initiatives (including on the impact and relevance of ethical frameworks for decision-making during the H1N1 pandemic, (17) the use of public engagement strategies to inform contentious public health policy development, (18) and PPE as a tool for deliberation and policy development (19)); as well as Selected Resources: Ethics in a Pandemic, and a Survey of Ethical Principles and Guidance Within Selected Pandemic Plans, all of which are or will soon be available, in both English and French, on the NCCHPP website (www.ncchpp.ca). In March 2011, the NCCHPP held a workshop to begin to define a common approach and workplan for the integration of ethics into public health practice and policy across all six of the NCCs (www.nccph.ca), and discussions clearly affirmed pan-NCC interest in developing PPH ethics resources and collaborative projects.

The NCCHPP aims to provide resources useful across a range of practices. This is based on indications that most Canadian public health professionals: 1) have little formal training in ethics; 2) prefer to learn about moral theory through both online resources and workshops that include practical case studies; 3) support access to formal PPH ethics consultation services; and 4) are especially interested in tools that assist them in dealing with empirical uncertainty, political interference, cultural diversity and material scarcity as these affect their decision-making.

The long-term NCCHPP objective is to serve as a platform for ongoing discussions of the core values, concepts and ethical issues related to all aspects of public health policy and practice. This work has begun with a concentration on pandemic planning and infectious disease control. In coming years, our scope will be expanded to include both specific topics (such as risk communication, health promotion, vaccination, and the precautionary principle) as well as issues that derive from a broader vision of the determinants of health and of the scope of public health practice (such as advocacy for social equity and justice, resource allocation for prevention, health in all policies and whole-of-government initiatives). Other projects underway, in collaboration with public health experts from across the country, relate to the integration of ethics frameworks into existing NCCHPP tools and guidelines for conducting Health Impact Assessments, public engagement strategies and advocacy campaigns, and the development of fact sheets and guidance documents on the politics of public health and the role of ethics in the policy process more generally.

Common approaches and opportunities across agencies

The CIHR-IPPH, NCCHPP and PHAC are working in complementary ways to advance the shared agenda for building the field of PPH ethics. Although each institution has their own mandate and target audiences, they share a commitment to knowledge exchange as both a strategic approach and a model for the integration of PPH ethics into practice. This has included hosting joint events and engaging in collaborative strategic planning. All three organizations aim to stimulate dialogue from local to national levels and across jurisdictional boundaries, and to raise PPH ethics literacy focused on practices and processes spanning research, policy and knowledge translation. We share the objective of ensuring that PPH ethics continues to develop as a distinct field of research and practice, and in so doing, that it becomes embedded within and across projects and sectors. The idea is not to standardize and institutionalize one approach to applied PPH ethics across the country; rather, the aim is to preserve, build and harness the pluralism of methods and approaches inherent to PPH practice in order to foster the emergence of ethical environments that make recourse to reflexive and deliberative strategies a matter of routine decision-making.

The approaches taken so far have included stimulating PPH ethics dialogue among PPH researchers and practitioners who encounter a range of ethical issues in their work or have a shared interest in giving greater consideration to the ethical foundations of PPH interventions. As shown by the ethics activities outlined above, all three organizations have encouraged the inclusion of a plurality of perspectives, experiences and disciplines which compose the fabric of PPH practice. Early efforts have engaged PPH scholars from non-traditional public health disciplines, including philosophy. The expanding scope of PPH ethics may also have important implications for researchers and practitioners who do not necessarily identify their intervention work as "health-related" (e.g., transportation, education), but whose decision-making and practice have significant impacts on PPH.

Initial work suggests that PPH ethics can serve the field in a broader way by promoting opportunities for all three organizations to take national leadership roles in bringing an ethics lens to bear on upstream PPH interventions and health equity--both of which are key to tackling social and structural determinants of health. (2) That said, much remains to be done and many questions remain unanswered, a few of which are highlighted below to stimulate dialogue on PPH ethics:

* The resurgence of interest in PPH ethics has been fostered in large measure by recent public health crises (e.g., the tainted blood scandal, recurrent e-coli contaminated water and lysteriosis-related illnesses, and the SARS and H1N1 outbreaks). Is it sufficient that public health emergencies drive the PPH ethics agenda or is there a more proactive role for PPH ethics to play in informing interventions to improve PPH more broadly, reduce health inequities and prevent such crises? How might PPH ethics achieve this? What is the risk in having PPH crises drive the ethics agenda? Is this too narrow an approach? How can ethics approaches be institutionalized as part of PPH practice?

* Given the extent of interaction garnered through the knowledge exchange and capacity-building activities outlined above, there may be an opportunity to consolidate interest through the creation of a national network for PPH ethics. Is there a need for such a network? Who are the key players to be engaged? How can sustained engagement with local, regional and provincial public health agencies be fostered in these activities in order to enhance linkages with front-line public health practitioners? What roles should national level actors take, and how should these be formally coordinated?

* How can research on PPH ethics be promoted and appropriately peer-reviewed? What are the priority research questions on PPH ethics?

* Core competencies suggest that public health ethics are an important dimension of "leadership" capacities.20 Should a code of PPH ethics be developed to guide practice and the selection of appropriate, effective or equitable interventions? Who should be involved in this process? Do existing frameworks adequately capture the distinct means and aims of PPH practice?

* With the expansion of Master's of Public Health programs and an increasing number of Canadian Schools of Public Health, there are opportunities to create resources and tools to support curriculum development, training and research on PPH ethics questions. Should there be a standard curriculum for PPH ethics in Canada?

* How might cases of population health interventions and public health scenarios be used to support application of an ethics lens in teaching and professional development? While work to date has been primarily within the health sector, engagement with other sectors that hold responsibility for the design and implementation of PPH interventions and the wider scope of whole-ofgovernment approaches will be a key strategy. Which are the key sectors to engage? How might intersectoral considerations be built into the design of ethics frameworks? How can NGOs and those working with vulnerable populations be integrated in these dialogues and discussions?

* Is there a role for national PPH ethics actors, perhaps in conjunction with national and provincial professional organizations, to develop guidance on professional ethics and conflict-of-interest situations? How can professionals (e.g., community health nurses, physicians, epidemiologists) be assisted, for example, in dealing with programs and policies that are contrary to known best evidence (either in the sense that research shows that some policies/programs do not or will not achieve stated aims, or that certain proven policies/programs are not being implemented due to political or social resistance)? What approaches would help PPH professionals confront situations that may generate conflicts between their obligations (moral and/or legal) and current or proposed programs/policies?

CONCLUSION

This paper presents a summary of current and planned ethics-related activities for three national-level organizations from public health research, policy and practice. The paper is intended to stimulate discussion of PPH ethics and the value of explicit ethical analysis and justification in the population and public health community, as well as to highlight the still-limited integration into policy and practice of well-defined and debated ethical values, competencies and frameworks. The hope of the authors is that this paper can serve as the impetus for an energizing conversation about ethics in our field and a departure point for the regular presence of PPH ethics-related work within the Canadian Journal of Public Health. It is time for the accelerating interest in PPH ethics to become galvanized into an effective community of practice.

Author Affiliations

1. Canadian Institutes of Health Research--Institute of Population and Public Health, Ottawa, ON

2. Public Health Agency of Canada, Ottawa, ON

3. National Collaborating Centre for Healthy Public Policy, Montreal, QC

Acknowledgements: The authors gratefully acknowledge the helpful input provided by Erica Di Ruggiero and Francois Benoit on earlier versions of this paper.

Conflict of Interest: None to declare.

Received: April 14, 2011 Accepted: July 4, 2011

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Correspondence: Sarah Viehbeck, Senior Evaluation Associate, Canadian Institutes of Health Research--Institute of Population and Public Health, 600 Peter Morand Cres., Suite 312, Ottawa, ON K1G 5Z3, Tel: 613-562-5800, ext. 1925, Fax: 613562-5713, E-mail: [email protected]

Sarah M. Viehbeck, PhD, [1] Ryan Melnychuk, PhD, [2] Christopher W. McDougall, MA, [3] Heather Greenwood, MSc, [1] Nancy C. Edwards, PhD [1]