Ethics, prevention and public health

Public health ethics has been receiving increased attention in recent years. Often, public health practitioners have to confront complex decisions, with numerous and often conflicting ethical implications. What to do: ask colleagues? try a literature review? consult a specialist in bioethics? The title of this book raises expectations of a treatise on the subject – a refuge for the public health practitioner with disconcerting questions. As stated in its preface, the book has come about as a result of encounters and discussions at meetings of the International Association of Bioethics held over several years. Some of the chapters result from a research seminar held in the Netherlands in 2002, while others have been written subsequently. The sixteen authors of the twelve chapters, all of which are original, come from Europe and North America, and range from a PhD student to luminaries in this field, such as Lawrence O Gostin. The book is very well structured, starting with an introductory chapter by the editors, Angus Dawson and Marcel Verweij, that provides an overview of what follows and discusses three general features of public health interventions. First, the initiative for public health interventions usually comes from a public health professional and not a patient who is seeking care; second, public health interventions may not be beneficial for each individual, but aim to protect and promote health at the group or population level; and third, public health activities are potentially pervasive and can interfere with all aspects of life and of society. The topics covered range from vaccination and herd protection as a public good, a non-paternalistic argument for tobacco discouragement, to the use of cost-effectiveness analysis for priority-setting. Most readers will restrict themselves to one or two chapters, with probably only a very few reading it from cover to cover. Personally, the book has enabled me to get a better grip on an issue that I have had in the back of my mind for some years. While informed consent is the hallmark of bioethics in health services, the complexity of interventions at the group and population levels makes it difficult to use the same standard for public health activities. For example, the increased use of combined vaccines in universal vaccination programmes (such as adding also a vaccine against chickenpox to measles, mumps and rubella vaccine) makes it impossible for parents to provide informed consent to each of the component vaccines involved. Although the individual and collective benefit and risk levels are different for each individual vaccine, a parent can at best only provide consent to a combined vaccine programme. In the final chapter of the book, Niels Nijsingh argues compellingly that requiring informed consent for a dramatically expanded newborn screening programme places too severe a burden on both parents and society in general, and that we need to find other means for protecting the individuals participating in public health programmes. Such an argument may be shocking to some, but it shows that this book does not provide ready-made answers for public health practitioners stumbling over ethical issues. Rather, it forces readers to reflect on these issues, deepen their understanding and arrive at conclusions that should be discussed with others. ■