Over the past several years, public health ethics has emerged as a distinct field of inquiry, reflecting a realization that principles and institutions developed since the 1970s to deal with ethical challenges in clinical and research settings are relevant to, but also insufficient for, addressing the issues that arise as policies and interventions affect (or neglect) health and its distribution at the level of populations. An international journal on Public Health Ethics was established in 2008; in the previous year, the Public Health Agency of Canada organized the first national roundtable on public health ethics, a remarkably stimulating one-day event in Montréal.
Several Canadian organizations have now collaborated to support the production of a casebook on Population and Public Health Ethics, published electronically by the University of Toronto’s Joint Centre for Bioethics. All cases submitted in response to a call for cases in 2011 were first peer-reviewed; accepted cases were then analyzed in a short essay by an invited author unconnected to the authors of the case. (Full disclosure: I was both a peer reviewer and the author of one of the case analyses.)
The result is a readable, intellectually challenging and hard-hitting collection of 16 cases dealing with issues as diverse as the ethics of public health surveillance; mandatory immunization of public health personnel; health status on First Nations reserves; and the health consequences of oil sands development. The cases are presented under three headings – research, policy, and practice – although it is sometimes difficult to identify clear boundaries among these domains. Readers are likely to cheer some of the analyses and conclusions, and perhaps to cringe at others. In my case, one of the major cringe-inducers is the frequency with which the theoretical frameworks cited originate with authors from south of the Canada-US border, despite the intellectual vitality of the health ethics enterprise in Canada.
But that’s the point. Stimulating debate and controversy about such questions is one of the ways in which initiatives like the new casebook add value to health policy and practice. Despite the last several years of intensive efforts to advance health equity as a priority, we lack effective public forums for discussing such basic questions as whether core competencies in public health ethics should be specified for practitioners. (The University of Toronto’s Ross Upshur raises this question in his introduction to the volume.) Next steps: perhaps a multi-agency research initiative on public health ethics, or a multinational conference on comparative perspectives and policy solutions?