Knitting Fog in Contested Space

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Knitting Fog in Contested Space Final
Session Public Health Ethics Conference,
University of Birmingham May 18th 2007
Jim McManus Assistant Director Health
Improvement Jim.mcmanus_at_bdpct.nhs.uk
Health Improvement
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Some Background

• Public Health Lead North East London Cardiac
  and Stroke Network
• Lead East London Specialist Public Health
  Training Consortium
• Healthcare Group, Catholic Bishops Conference of
  England Wales
• Emergency Planning Working Group Dept of
  Communities and Local Government
• Lord Chancellors Appointment
• Ethics Committee, Secretary of State for Work and
  Pensions

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Summary

• The Nature of Public Health
• The Contested Space of PH and PH Ethics
• Implicit and Explicit Change
• The Experience of other such disciplines
• The Need for Coherence and Robustness
• The Need to inform Practice
• Steps toward a partial agenda

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What is Public Health?

• A set of tools and methods which have a
• Population perspective
• A Prospective Orientation
• A Preventive Ambition
• And Protective Intent, producing
• Probable actors (sometimes)

Qui probabiliter agit, prudenter agit Alphonsus
Liguori
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Either..

• Public Health is a conflicted and compromised
  function without coherent core
• Apply a hermeneutic of suspicion towards this
  compromised thing
• Art not Science politics not ethics

• Public Health is a Genus, not a Species of
  Actions which are a Contested Space
• The only ethical project which will work comes
  from a hermeneutic of generosity towards this
• Art and Science

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Contested Space

• Anderson, Imagined Communities Reflections on
  the Origin and Spread of Nationalism.
• Gianni, Multiculturalsim and Political
  Integration The Need for Differentiated
  Citizenship, in Wicker, Hans-Rudolf
  (ed.),Rethinking Nationalism and Ethnicity The
  Struggle for Meaning and Order in Europe.
• Policy Network Theory (Public Administration)

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Features of Contested Space

• Everyone wants a piece of it
• Or alternatively nobody wants a piece of it
• (At least implicit) Competition for Authority
• Uncertainty about many things
• Complexity
• Constantly problematic
• The dirty business we heard of yesterday

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The Contested Space of PH Practice
Self
Multiple Organisations
Health Promotion
Policy
Public
Contested Space of Practice
Health Protection
Health Services Quality
Law
Patient
Profession
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Contested Space Because

• Diverse Foci
• Individual, Population. Prevent, Protect.
• Diverse Methods
• Diverse Sources
• Authority, Authenticity, Priorities
  (Law,Policy,Finance)
• Diverse Norms
• Processess, Methodologies, Tools, Ethical
  Principles
• Diverse Problems
• Possibly radical contradictions in its different
  foci

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The Contested Space of PH Practice
Self
Multiple Organisations
Health Promotion
Methods, Sources and Ethical Norms
here Community Engagement Authenticity/Author
ity Of Ethics comes from Social Participation
Public
Health Protection
Health Services
Contested Space of Practice
Patient
Profession
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The Contested Space of PH Practice
Self
Multiple Organisations
Health Promotion
Methods, Sources and Ethical Norms here
PROTECT PREVENT Internal and
External Sources of Authority Deontology Utilitar
ianism Communitarianism Teleological Accounts
Public
Health Protection
Health Services
Contested Space of Practice
Patient
Profession
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The Contested Space of PH Practice
Self
Multiple Organisations
Methods, Sources and Ethical Norms here
HYBRID Community Engagement ethical
issues From Health Promotion AND ethics of
evidence AND Deontology Utilitarianism Communitar
ianism Teleological Accounts From Health
Protection
Health Promotion
Policy
Health Protection
Health Services
Contested Space of Practice
Law
Profession
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The Contested Space of Public Health

• A range of different professions from Core
  Statutory Public Health through Statutory
  Environmental Health, through Public Health
  Activism to Legal and Policy issues
• Chaerobics (not a friend of Asterix)
• London Resilience (Security Services)
• Individual Funding Applications (Transgendering)
• Contaminated Land (Nice shrubs, poor health)
• Vulnerable Peoples Protocol (Flood, Heatwave)
• Prioritising service developments (Nurses or
  Buildings)

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Views from Practitioners..

• 20 focused interviews
• 1 Focus Group

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PH Ethics is also contested space

• Sugarman and Sulmasy (2001) Medical Ethics cannot
  survive without drawing on a range of sources and
  methods (norms)
• Law, Theology, Economics, Political Economy,
  Philosophy, History
• In Reckless HIV Transmission, the Lord Advocate
  decided Public Health Ethics for us
• Openness about our sources (The dominance of
  different philosophical traditions in different
  countries)
• These sources effect change and change themselves
• Implicit changes in how PH is done
• Explicit policy shifts

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Challenges to Individual Rights Medical Ethics
Reading of PH Ethics

• Voluntary Sector practice of Public Health
• Improvement in health status (almost an
  aesthetics of health)
• Health as linked to life opportunities
• Contestability of smoking
• Heaviest smokers are social class IV women
• Highest mortality in poorer populations
• Is it right for PH agencies to consider the
  relative vision of health (smoking is healthy
  for me) when the people who win are still the
  educated middle classes?
• Health Trainers - Just trying to make people
  middle class

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Challenges to Individual Rights Medical Ethics
Reading of PH Ethics

• Local Government Systems
• Most PH systems in world go far beyond health
  services to issues like sanitation, food safety.
• These are not just givens
• The issue of when one can interfere in rights
• Relativity and Contestability Serious or
  fallacious?
• How close to anarchy does problematising the role
  of local government or health services come?
• Sounds very western
• A discourse from power?

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Problematise or Celebrate?

• The possibility of a PH Ethical project is a
  problem, just as PH ethics is a project which
  falls down in liberal individual terms
• Other problems
• The ethical Academy has no obvious legitimacy
  among the profession
• The profession has no obvious legitimacy among
  the Academy

• The change in sources and norms shows PH is alive
  and relevant as a set of disciplines
• Non medical sources of norms and ethics are
  welcome, not difficult
• It is not an either liberal individualism or
  communitarianism issue
• Pragmatics of different norms and approaches is
  the only orientation that is going to work?

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The Problem of Population Focus The Locus of
Community Agility within PH Ethics in Practice?
Increasing impact on community
Greater importance given To community
Increasing impact on individual
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The Locus of Community A modified
communitarianism
Reciprocity Individuals who Have rights
also Have duties to Society, including A duty to
the Health of the public
Increasing impact on community

Applied in MDR TB in the UK?
Increasing impact on individual
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The Do-ability of PH EthicsPractitioner Views

• Contingent upon this malleability
• A possible way out of the problem of Locus Standi
• Does the ethical Academy have any obvious
  legitimacy with the profession
• And its not just the profession
• Meta-narratives of suspicion are themselves
  meta-narratives.
• They dont get us anywhere
• sBut then neither may what I am proposing?

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The Experience of Other Disciplines - Psychology

• Contested between the State, Industry, Academy
  and the Profession
• The diverse functions of psychologists
• Development of ethics to protect the profession
  as well as the public?
• Describe, Diverse, do not delimit
• Still left with a PROFESSION Hello Foucault!
• Creation and revision of explicit sources and
  norms of authority
• But arguably has been for the better

Better Hearts
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The Experience of Other Disciplines Applied
Criminology

• State Funding for criminology research represents
  some 90 of available funding
• Ethics of researching people who disclose major
  crimes
• HMP Lambeth Crack Cocaine Dealers
• Feminist and Left Realist critiques of
  Criminological Research social obligations or
  government contractors
• Applied Ethics for practice as a means of
  preserving integrity

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A Suggested Agenda orIts not modified
utilitarianism, honest

• PH will never fit into a medical ethics mould
• A hermeneutic of generosity
• Recognise the mutability of PH practice or bust
• From nation to nation
• From issue to issue
• Ethics proper or Ethics Improper
• Q When is Law an Ethical Source?
• A When its encountered by a public health
  professional

• Provide a malleable set of ethical principles A
  pragmatics or Aesthetics of public health comes
  before Ethics
• Rights and Duties must be co-considered the
  Locus of Community in Public Health Ethics must
  be a co-principle with the locus of the
  individual
• The narrative of mutual obligations making up the
  social contract problematic of PH seen as
  enforcers

Fewer Deaths
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A Suggested Agenda orIts not modified
utilitarianism, honest

• There are some principles which, though
  problematic in an individual focus, have enduring
  value in a public health context
• The Harm Principle
• Egalitarianism
• Communitarianis
• Teleological Anthropology

• The issue is not that these principles are
  problems in themselves, but the issue is how we
  combine them malleably
• Not being unprincipled, but multi-principled

Fewer Deaths
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Norms or emergent themes?From interviews

• You will act Authentically
• Fitting the norms and principles to the situation
• Without extreme situationalism
• Acknowledging the limits of your own competence
• You will act Prudently
• You will seek to balance the needs of community
  and individual to the best benefit of both
• If you must do harm, it should be proportionate
  and proximate

• You will act Purposefully
• for the best health outcomes as you see them
• having due regard to evidence, policy, law
• and your conscience
• You will act Probably the best evidence or
  proven course of action for the issue you face
• You will act Transparently
• You will act Accountably

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Public Health as Genus, not Species

• There may never be a single public health ethics,
  because there is no single thing as public health
  practice..
• There are public health practices.
• Competency 10
• Manage self, resources and others ethically

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Even if you disagree with this

• The notion of contested space has salience as a
  test of the relevance of PH Ethics in practice
  situations
• Can there be a PH Ethics which isnt intimately
  linked to PH Practices?

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Conclusion

• PH as Contested Space
• PH Ethics as Contested Space
• Norms and sources are not stable, and probably
  ought not to be
• Practitioners want the project of PH ethics to
  help them live in contested space
• Can philosophy help provide this?
• There is a possible, if problematic, agenda

Better Borough
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Thank You!

• Jim McManus
• Asst Director Health Improvement
• Barking Dagenham PCT
• The Clock House
• East Street
• Barking IG11 8EY
• Jim.mcmanus_at_bdpct.nhs.uk
• www.bdpct.nhs.uk

Proud of our People, Proud of our Borough