LGD 2004 (1) - Robyn Martin
Public Health Ethics and SARS: Seeking an Ethical Framework to Global Public Health Practice
Robyn Martin
Research Professor in Public Health Law,
Centre for Research in Primary and Community Care,
University of Hertfodshire, UK
r.m.martin@herts.ac.uk
The outbreak of SARS has made clear the global potential of threats to public health, and has prompted a rethinking of public health policy, networks and practices at both domestic and global level. Global co-operation on issues of public health requires an agreed global framework of understandings of the objectives and mechanisms of public health. The tools of law and human rights jurisprudence in the formulation of such a framework have not proved effective. The author argues that there is need for a discrete framework of public health ethics, based not on codes of medical ethics, bioethics or research ethics, but developed to recognise the fundamental concerns of public health. The viability of such a code and its possible shape and content are considered in the context of the global fight against the spread of SARS.
Keywords: Public Health, Ethics, SARS, Globalization, Global Framework
Author’s Note
This paper originated in a presentation to the Hong Kong Hospital Authority in October 2003. The author was working in Hong Kong during the peak of the SARS epidemic in March and April 2003.
This is a refereed article published on 4 June 2004.
Citation: Martin, R, 'Publci Health Ethics and SARS: Seeking an Ethical Framework to Global Public Health Practice', Law, Social Justice & Global Development Journal (LGD) 2004 (1), <http://elj.warwick.ac.uk/global/04-1/martin.html>. New citation as at 15/07/04: <http://www2.warwick.ac.uk/fac/soc/law/elj/lgd/2004_1/martin/>.
The outbreak of Severe Acute Respiratory Syndrome (SARS) in March 2003 provides a useful vehicle for examination of the ways in which states and health providers prepare for, and deal with, major threats to public health. SARS made a significant impact on public perceptions of disease. During the height of the SARS outbreak there was public and media-generated fear of contagion much out of proportion to the reality of level of threat. SARS also had a major impact on institutional responses to the threat of disease. The WHO and the Department of Health in the UK[1] , continue to maintain a discrete website devoted to information on SARS, although there are no known cases of the disease in existence at the time of writing. The total world mortality rate from SARS[2] was low in comparison with deaths from more common public health threats such as TB or AIDS, or compared with the many thousands thought to have died as a result of exposure to excessive heat (la canicule) in the European summer of 2003[3] .
There may be several explanations for the reactions to SARS. The speed of contagion, the mystery surrounding the origin of the virus, and scientific uncertainty contributed to some irrationality in public and media responses[4] , and the impact of SARS on developed populations made it newsworthy in a way that diseases such as malaria have not proved to be. The prospect of profitable pharmaceutical intervention may have helped to attract the interest of countries with research resources. For all this, two particular lessons for public health policy makers and providers have emerged from SARS. The first is that SARS has made evident the real global potential of infectious disease. The second is that current frameworks for response to newly emerging diseases are inadequate to protect the public health.
We have always known from the spread of diseases such as cholera and syphilis, and more recently from the spread of HIV/AIDS and the re-emerging TB pandemic, that disease has the capacity to cross borders, and that increasing world travel, migration and trade contribute to increasing globalisation of disease threat. What SARS brought home to us was not so much the speed and ease of disease spread, but rather the speed and importance of globalised responses to disease. For the first time there was world-wide co-ordinated use of, and reliance on, the internet as a major, if not the major, form of communication about disease at public and institutional level[5] . The WHO website provided one focus for the immediate exchange of health information and statistics on SARS, but the websites of state health services, medical science research centres, health NGOs, newspapers and individuals also served to deliver health information contemporaneously across the world. Not all such information was accurate, scientific or official, but there is no doubt that much of the essential information gathered in the fight against SARS was transmitted in electronic form[6] .
To say that SARS and the responses to SARS were globalised is not to say that they were universal. SARS was not universal in the degree of impact on different populations, posing as it did a serious threat to the health of people in China, Hong Kong, Vietnam, Singapore, Taiwan and parts of Canada with very limited impact elsewhere. Nor were responses to SARS universal. Some states conferred strong positive powers and duties on institutions and individuals to behave in ways which reduced the threat of disease[7] . Some states strengthened existing public powers to bring into play powers of notification, detention, quarantine and treatment[8] . Some states chose not to make SARS a notifiable disease[9] . Still other states have no powers of quarantine or detention in relation to any infectious disease[10] .
The second lesson learned from the SARS outbreak suggests that there is a need to rethink public health policy, practice and networks in such a way as to facilitate eradication of new public health threats. Despite informal networks of information exchange provided by the internet, avenues of formal information exchange on the existence and spread of disease proved clumsy and inadequate, and formed barriers to preparation of disease prevention strategies[11] .
International public health communication infrastructures require a global understanding of public health objectives, and global agreement on the processing of health information. This is not to say that there must be a universal approach to disease prevention and eradication. Different states come from different cultural and historical starting points, and universality of response would require an overriding of social and cultural belief systems.
However it might be possible to agree a general, global moral framework of response to serious, dynamic public health threats which would provide the basis of communication and negotiation between individual states. Such a framework would serve to provide a common language of public health, based on globally agreed assumptions about the moral mandate of public health.
2. Globalisation, Law and Human Rights
Globalisation has been defined as ‘the process by which events, decisions and activities in one part of the world can come to have significant consequences for individuals and communities in quite distant parts of the world’(McGrew 1992). Globalisation suggests dissolution of state borders enabling almost contemporaneous world movement of people, money, goods, information and values. It suggests a ‘collapse of the space-time distinction’ (Held 2000) in relation to goods, ideas and ideologies.
Globalisation has been fuelled by air travel, banking practices and the internet, but it has been driven by market capitalism. It has resulted in twenty-first century imperialism (Evans 2002), in which the colonisers are those states with dominant technologies and resources. Globalisation confronts cultures, histories, geographies, traditions, religions and communities. It has the potential to result in a global apartheid (Alexander 1996) dividing the haves from the have-nots, and so has prompted protest from grass roots activists and from states and populations who perceive themselves as exploited by globalisation rather than benefiting from it.
Whatever stance we might take on the process of globalisation, we cannot ignore it. SARS has demonstrated that globalisation can dictate the course of disease, and to preserve the health of our populations we must work to contain the consequences of globalisation by developing a globalised framework of responses to the progress of threats to health. The question which then arises is, what tools would best enable us to formulate such a framework?
One possible approach would be to develop a legal framework to public health policy and practice. There are difficulties with using law to regulate at global level. Most law acts intra-jurisdictionally, and national laws vary from state to state, reflecting different beliefs and understandings of the power of the state over individual citizens. Nor has international law has proved effective in global regulation, particularly in the context of health.
Fidler notes that ‘…international health law goes far beyond what WHO may adopt under its international legal powers and involves diverse international legal regimes developed in different contexts by differing international and non-governmental institutions’ (Fidler, 1999, p 39). In the sense that laws with health consequences, such as laws regulating employment, the environment, trade and consumer protection, have been influential in the regulation of health, international law has played a useful role in health protection. However the potential of international law to constrain health threatening activities, or directly to enforce health protection measures, has not been realised, and the law making powers of the WHO have rarely been exercised. For more than half a century, ‘the WHO’s power has lain dormant, with the adoption of no single treaty or agreement and with the drafting of only two regulations’ (Arai, 2001). It has been commented (Arai, 2001) that international law is limited in its capacity to override state laws, and that:
‘…any attempt to adopt and enforce binding legal instruments would prove counterproductive in face of the power balance between national sovereignty and the mandate of international organisations. To enforce treaties and agreements is dependent on the goodwill of Member States, which vie for sovereign power and are unwilling to compromise it.’
The most important international health law instrument, the International Health Regulations, aimed at ensuring ‘the maximum security against the international spread of diseases with a minimum interference with world traffic’[12] has created obligations of disease notification, monitoring at frontier posts and measures in relation to international transportation of goods and persons[13] . However there is evidence that states are failing to comply with these obligations because of the economic consequences (Allin, 1998, Chen, 1999).
There has been little attempt to introduce or adapt health regulations to address global threats to health presented by the increasing mobility of infectious disease (Taylor, 1997, p 1333), although revision of the IHRs is currently being undertaken ‘to develop Regulations which will be applicable to the epidemiology of communicable diseases and international traffic in the 21st century’ (WHO, 1999, p 252, Arai, 2004). Commentators have suggested that reluctance by the WHO to use its legal powers to implement wider public health objectives stems from the dominance of scientific medicine and its practitioners within the WHO, prioritising medical and technical solutions to health threats over social and legal responses (Taylor, 1992, p 303, Fidler 1998, p 1099, Arai, 2001).
It is in any case questionable whether law is always an appropriate vehicle for achieving co-operation and compliance between states on matters of health. Implementation of law is a slow process, particularly at international level where processes of adoption, ratification and entry into force mean that health protection measures lag long behind the eruption of public health threats. Law may apply too heavy a hand in the sensitive area of health behaviours within a context of traditional and cultural ways of living, and the application of law may result in a counterproductive resentment and suspicion of public health interventions.
Another tool which might potentially provide a framework for global public health is that of human rights. Human rights instruments establish recognition of a broad range of civil, political, economic, social and cultural rights, many of which impact on health. The employment of human rights language and concepts to underpin global public health has been proposed by Gostin and Lazzarini, who recommend undertaking a ‘human rights impact assessment’ in relation to all public health decisions (Gostin and Lazzarini 1997, p 66). However while there has been general international agreement to and acceptance of the United Nations Commission on Human Rights’ International Covenant on Civil and Political Rights, there has been less universal enthusiasm for the imposition and enforcement of the International Covenant on Economic, Social and Cultural rights, such that the process of enforcement of the ICSECR is subject to the principle of progressive realisation and constrained by state resources[14] .
It is the Covenant on Economic, Social and Cultural rights which has most relevance to public health. Article 12(1) of the ICECSR states that party states must ‘recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’. Worthy though this statement is, it is subject to two variables: that of ‘highest attainable standard’, and that of understandings of what constitutes health. The notion of highest attainable standard is hostage both to overall state resources and to state spending priorities. Where for example public spending on defence is prioritised, the highest attainable standard within the remaining resources might be unacceptably low. Nor is the content of the notion of ‘health’ internationally agreed. The content of health in some states in relation to women and children may be considerably below that regarded as essential in others.
Human rights instruments have, for all this, made considerable achievements in global recognition of what states should be working towards in the attainment of health. The ICESCR makes particular mention of child health, environmental and industrial health, disease and the provision of health services. Other treaties directly and indirectly address the rights of particular vulnerable groups in the context of health[15] .
Yet it is arguable that human rights instruments, like law, are limited in their application to public health. One problem is achieving global agreement on the content of rights, and it has long been argued that the concept of human rights and the content of rights, have been dominated by western political and philosophical thought to the exclusion of beliefs of other cultures (Shivji, 1994). The American Anthropological Association as far back as 1947 criticised the Universal Declaration of Human Rights for not including a statement of the rights of citizens to live in terms of their own traditions, and characterised the declaration as an attempt to impose western values on other cultures (Banda, 2003). The Bangkok NGOs from Asia Pacific Declaration on Human Rights notes that, ‘…while human rights are universal in nature, they must be considered in the context of a dynamic and evolving process of international norm setting, bearing in mind the significance of national and regional particularities and various historical, cultural and religious backgrounds’ (cited by Cerna, 1994, p 102)
It is clear that human rights debates have a political dimension which inhibits global acceptability of the content of human rights. An examination of the universality of human rights is beyond the scope of this paper, but it is sufficient to note that a framework which is politically contentious will not serve the purpose of providing a basis of common assumptions for globalised public health.
Even if we could agree a minimum content of human rights, it may well be the case that while obligations on states to protect the rights of individual citizens will suffice to provide a framework for protection of some basic individual rights to health, the focus on individual rights makes human rights jurisprudence inappropriate for protection of the health of populations. This is not to ignore the contribution that addressing rights has made to the public health in some circumstances, for example in the context of AIDS (Harrington, 2002). Nevertheless it is arguable that to speak of health protection in terms of rights is in itself counterproductive. Public health involves prioritising the public good over the rights of individuals[16] , and at times requires balancing of the rights of some members of the population (who might for example argue that they have the right to smoke) against the rights of others (who might argue that they have a right to clean air). Human rights arguments are more appropriate to arguments about individual clinical treatment than to public health.
The language of human rights is confrontational and adversarial. Public health is most effective in an environment of co-operation and compromise, and rights arguments do little to assist in the determination of collective best interest. Public health must recognise and abide by universally agreed human rights, just as it must recognise and abide by international and domestic laws. But human rights, like law, are neither sufficient nor appropriate to provide an overarching framework of public health practice.
The third possible tool for formulation of a global public health framework is ethics.
It is now generally accepted that ethics are integral to health care. Ethics differ from human rights arguments in that they are about standards and responsibilities rather than rights. Ethics are a statement of values, virtues and responsibilities that helps us to distinguish behaviours or policies that are legitimate from those that are unacceptable. Ethics provide a coherent and consistent code of morality which in the context of health can serve to enhance scientific quality, to monitor scientific misconduct, to promote good practice, to reduce health harms and to encourage health benefits.
We need ethics to provide an overarching framework for medical science. Science is positivist in nature, making statements or claims about what is the case. Ethics is normative, making statements or claims about what should, or ought to be, the case. Although science purports to be neutral and value free, the reality is that both science and ethics are value laden. In science the values are concealed, but they will influence how a medical problem is defined, who is appointed to solve the problem, and most importantly, what happens to the results. In the context of infectious disease, political and professional values might dictate keeping scientific information concealed to enable economic exploitation or career prestige, or to avoid the stigma and economic consequences of a WHO classification as a disease infected area[17] . In the case of medical research, the economics of patenting of science might dictate what happens to medical information.
Ethics too is value laden but the formulation of a framework of ethics requires acknowledgment, open debate and clarification of those values. Agreement on fundamental underlying values is necessary to an agreed framework of ethics, and an understanding of those values enables us to recognise the values inherent in science.
Ethics serve functions other than supervision of science and scientific research. Ethics provide a statement of assumptions and understandings about health to form a basis for health dialogue. Ethics symbolise the integrity of health practice, while at the same time providing a practical guide to integrity of practice. Miké suggests that ethics serve ‘as a beacon to warn of the danger and to show the way - as a lighthouse…’ (Miké, 2003, p 138).
Having determined what ethics are, then the question arises as to what sort of ethics apply in the context of public health. Four levels of ethical responsibility can be identified.
The first level is that of personal responsibility, both of the individual and the health care practitioner. Much of the writing on ethics is concerned with this level of responsibility, reflecting the fact that ethics derive from the moral philosophy of a time when medicine was practised by individuals outside a professional framework (Rodwin, 1998). Personal ethics require that all persons have a responsibility to do good (the duty of beneficence) and a duty not to cause harm (the duty of non-maleficence) (Aquinas, 1959, pp 121, 179).
The greater the risk of harm to others, the stronger the duty not to cause harm, and the greater the personal responsibility for the safety of others. In the context of a disease such as SARS, personal ethics suggest that members of a community might take more precautions than usual for the protection of others, by, for example, taking unusual care on matters of cleanliness and hygiene, positively monitoring themselves for symptoms of disease, and adjusting social behaviours to avoid exposure to disease. Sufferers of disease create greater risk and so bear greater moral and possibly legal (Brazier and Harris, 1996) responsibility for damage limitation to others. Of course all these precautions might apply equally to the common cold, but as responsibility is related to risk, the obligations are not so pressing in that case.
Norms of personal responsibility might include respect for others, preparedness to shoulder some burdens for the benefit of others (what Livovich, 2001 categorises as self effacement and self sacrifice), compassion, truthfulness and integrity. These values apply equally to the individual and the professional, but the greater risk posed by professional misconduct creates a greater obligation on the health provider to assume personal responsibility.
The second level of responsibility might be characterised as professional responsibility. This encompasses both the responsibility of a professional group to instil and monitor good practice within the profession, and responsibility of individual members of a professional group to abide by professional norms. Such norms will include medical ethical principles of respect for privacy and autonomy, beneficence, non-maleficence and truth telling alongside good practice requirements of compliance with professional guidelines and in the case of health, evidence based medicine (Beauchamp and Childress, 2001). Considerable attention has been paid to ethics in the professional context, and literature on medical ethics and bioethics focuses on professional responsibility. The content of professional good practice may vary from country to country, but most in states there is an understanding of professional ethics in the provision of medical services.
The third level of responsibility is that at institutional level. This applies to government and non-government bodies who take responsibility for the positive good health of a community or state. These bodies may or may not include professionals bound by professional ethics, and may or may not be dealing with persons in need of medical treatment. Such bodies may institute health policies, develop health promotion and health education, and monitor health provision. They may also take responsibility for ensuring justice in the allocation of health goods. It is within the level of institutional responsibility that public health largely falls, and there has been less attention given to ethics at this level.
Lastly there could be said to be responsibility at public level. This is the responsibility of states and governments, and individual members of government, to behave in accordance with accepted norms of public policy ethics both to enable administration of justice, and to serve as role models for the behaviour of citizens. Public responsibility in health would require ensuring that populations and individuals within populations are provided with the best possible environmental and social conditions for health, whatever the debate as to what these conditions might be. This responsibility may include auditing of professional bodies and health institutions, and responsibility for passing legislation to enforce good practice where appropriate. Public policy ethics have been recognised as essential to public life (Nolan Committee, 1995; MRC, 2002).
4. Why We Need a Discrete Statement of Public Health Ethics
If we are to consider the development of a code of ethics with application to public health, it is to the third level of responsibility, that of institutional responsibility, that we must turn.
The role of public health is essentially a moral, quasi-religious one. Public health takes responsibility for health in its widest sense, and goes beyond the physical health of the people to responsibility for social environments, health behaviours, health attitudes and health beliefs. Public health practice does not come into play at the request of a patient or a community of patients, but works to its own agenda for the public good, imposing its own values on the community.
Public health practice involves preaching in the form of health promotion and education. Public health admonishes anti-health behaviours such as smoking and unhealthy eating. Public health dictates behaviours such as requiring people to stay at home when they are suffering from infectious illness or to keep away from public places to avoid exposure to disease. Public health punishes non-compliance either directly, through the imposition of detention or fines[18] , or indirectly by withdrawing health services for ‘self-inflicted’ illnesses[19] .
This moral mandate of public health means that public health must operate according to accepted and understood moral principles. It is often assumed that codes of medical, bioethical and research ethics provide a sufficient ethical framework to public health practice[20] . However there are a number of ways in which public health practice is essentially different from medical practice.
Public health deals primarily with populations or communities (NHS Executive, 1999, p 6) while medical practice deals primarily with individuals or families. Public health works to pre-empt illness, focusing on prevention and promotion - what has been called ‘upstream thinking’ (Thomas, 2003) - while medical practice focuses on cure or palliative care. In public health, policy decisions are made by governments and institutions, while in medical practice decisions are primarily made by health providers or the employers of health providers.
The focus of medical ethics is on the relationship of the health provider with the ill patient. Public health often deals with persons who are well. In medical treatment it is the same person, the patient, who bears the risks and benefits of treatments, whereas in public health the risks and benefits are often borne by different people. Very different ethical difficulties arise in these circumstances.
Medical science and bioethics rest heavily on the science of evidence based medicine in their determination of good practice. Evidence based practice results from randomised controlled trials (RCTs). Public health is often not about achieving scientifically measurable outcomes, but rather about goals of health improvement and education. The WHO has pointed out that in the context of public health RCTs are likely to be misleading and unnecessarily expensive (WHO Working Group, 1998 cited by Stewart-Brown, 2002). While RCTs work best when the intervention and study methods are entirely controlled by the researcher, health promotion and improvement work best when those who are likely to suffer the burdens and benefits are involved in the policy making. Public health interventions work best when they are participatory (Stewart-Brown, 2002).
For these reasons we cannot assume that codes of medical ethics, bioethics or research ethics will suffice to regulate good public health practice. Such codes might even be inappropriate and counterproductive to public health. In determining a framework of public health ethics we must start with a clean slate, and develop our code from first principles.
5. The Nature of Public Health
It might first be useful to identify some fundamental concerns of public health.
The first fundamental concern of public health is the notion of risk. The NHS Executive (1999, p 59) notes that ‘the concept of risk is essential to public health practice’ and defines risk as ‘...the chance or probability that something (usually undesirable) is going to happen’. The need to identify, assess and manage risk has now permeated public policy decision making in general (Fisher, 2000), and health decision making in particular (Chief Medical Officer, 1997).
All medical treatment involves risk, but risk is particularly problematic in public health where the risks and benefits may be uncertain. This uncertainty applies to how risk is measured, how health policy should reflect scientific risk measurement, how risk is perceived by individuals and populations, and how risk is communicated to individuals and populations. Public health is concerned not just with scientific risk but also social risk, such as the risk of stigma or discrimination. The notion of risk takes on greater importance in so far as it is accepted that individuals and communities have the right to make their own health decisions, since public health authorities must use risk arguments to justify overriding individual choice.
Calman (1996) points out that the way in which people perceive health issues and risk, and the way in which they make choices about their own behaviour does not always fall into a rational pattern. The concept of relative risk is particularly difficult to communicate, as are the ideas of justifiable and unjustifiable, acceptable and unacceptable, serious and non-serious and community risks (Calman and Royston, 1997). Calman (1996) cites Kant, ‘We see things not as they are, but as we are’, such that each person perceives risk in relation to his or her own personal circumstances. Any ethical framework for public health will need to address the issue of risk, and in particular truthfulness in the presentation of risk factors and probabilities, criteria for measurement of benefits against burdens, and clear allocation of responsibility for risk choices.
The second fundamental concern of public health is the issue of justice. Justice is addressed in medical ethics in the context of allocation of health resources between competing individuals, and there is considerable literature on the role of justice on this point (Gillon, 1985; Harris, 1985). Justice in public health however is more complex because public health has a moral mandate to further social justice in relation to the conditions for good health. Public health is not reactive to patient need but rather sets its own agenda, and in doing so public health takes on responsibility for the elimination of avoidable and unnecessary inequalities in health (Wanless, 2004). This is a much greater responsibility than making an ethical decision as to treatment between competing patients, or choosing between competing health resources. It means actively seeking out inequalities and addressing them. Some inequalities in health and access to health resources may have traditional or cultural explanations, and so justice in this context may require confronting cultural discriminations. There will be public health responsibility for educating the community, not just the professions, to enable understanding and acceptance of principles of justice in the distribution of health goods.
Justice requires that public health actively enhance health goods while at the same time maximizing individual freedoms (WHO 2000). Justice also requires that public health practitioners develop an awareness of the wider implications of health interventions. Identification of those exposed to disease might facilitate reduction in disease incidence, but might at the same time create stigma (Scrambler 1998) such that identified persons are excluded from the community. This could constitute discrimination infringing human rights law and result in the creation of other health problems. Public health practitioners must develop an awareness of the influences which determine health interventions. Have assumptions been made about the health behaviours of particular groups leading to increased public health attention, and greater interference in the privacy of members of those groups[21] ? Any public health framework must include provisions advocating an equitable distribution of health, not just an equitable distribution of medicines and treatments.
A third fundamental concern of public health is the issue of community. ‘Public health is about the health of populations or communities’ (NHS Executive, 1999). A community might be a whole population, a geographical neighbourhood, or a family group, or it might be an identifiable group of people with a common health or social need. While doctors treat patients, public health does not treat communities. Public health is a joint activity involving the community, public health practitioners and the state. Public health works most effectively when policies and interventions are negotiated with communities, and least effectively when policies and interventions are imposed on communities without seeking and maintaining public trust and support (Anderson and Florin, 2000). History shows us that attempts to impose compulsory smallpox vaccination without first convincing the public of the medical desirability of vaccination resulted in riots and protests in the UK (Durbach, 2000). Similarly public concern about the MMR vaccine, and the consequent low take-up rate, have been attributed to the fact that ‘the chief medical officer would not meet parents’ concerns half way by sanctioning access to single disease vaccinations’ (Bellaby, 2000). It has been noted in the context of MMR that ‘transparency and openness are now the only reliable routes to winning public trust’ (Science Media Centre, 2002).
A community is more than the sum total of a collection of individuals. There is added value in the network of relationships that might make up a community. Public health practice must recognise and respect the community as an entity, and good public health practice uses community values and goods to its advantage. The added value of a community, the gain to the individual from being part of a social and informational network, is known as social capital (Policy Innovation Unit 2002). There is a relationship between social capital and health inequalities (Kawachi, 2001; Hean and Cowley, 2002), and working to increase social capital by developing community trust and networks can serve to improve population health (Cowley and Hean, 2002). For this reason an ethical framework to public health must accommodate the notion of community as an identifiable health good contributing to the conditions for health, rather than as a subject of public health services.
6. The Possible Shape of an Ethics Framework for Public Health
Having identified some fundamental characteristics of public health, how can we go about formulating a set, or code, of ethics which recognise these characteristics? Because public health is so different from the practice of medicine, it would not be helpful to start with a code of medical ethics or bioethics and attempt to adapt it to public health. To ensure that our ethical framework is best suited to the needs of public health, it would be best to start from scratch.
There are three main alternative approaches we can take to ethics. One, the deontological approach, proposes that an ethical framework consists of a set of agreed principles or rules of behaviour which should be followed whatever the circumstances and whatever the consequences. Individuals in their private lives tend to have an internal set of principles, derived from religious or family or community values, which they use as a reference point in their decision-making. Public health might similarly draft a set of principles as a basic reference point for practice. For example we might adopt a principle that no individual should be harmed for the benefit of another. If we accept this as a rule of practice, then it must be a universal rule and we must abide by it even if it is not convenient or helpful to do so. In most cases we would want to comply, but there may be situations where we think it would be right to breach it, for example to vaccinate a baby boy against rubella for the protection of pregnant women and their babies, or to detain someone with infectious tuberculosis and who refuses treatment for the protection of people around him.
A second approach, the utilitarian or consequentialist approach (Mill, 1888), determines the extent to which something is ethical by the good that results from it, and so is more concerned with context than with rules. Many of the day to day decisions people make in their private lives are based on a consequentialist approach, asking which option will make those affected happier or richer. If we were to take this approach in public health we might assess each public health policy or intervention to determine whether it does more good than harm, and opt for the choice which seems to give the most effective (in scientific, social or economic terms) outcome. So when faced with a highly infectious disease like SARS we might conclude that the best way to eliminate the spread of disease would be to banish all infected persons and their contacts to a remote and unpopulated place to remove all risk to health care workers and the general population. Such a move would probably be effective, but we might feel uncomfortable with it not because we think it won’t work, but because we think deep down that we owe a duty to care for the sick, and that health care workers have responsibilities even when they might be put at risk in the exercise of those responsibilities. We could of course choose to take an approach to utilitarianism based on ideal rules rather than acts, assessing instead which rule would give rise to the best consequences (Harris, 1997), but in practice we tend to look to the particular rather than the general when make judgements about consequences.
The third approach to ethics rejects the cold, rational neutrality of approaches which either apply rules blindly and universally, or which calculate material benefit in order to dictate behaviour. This approach has several versions, the most common of which are the ethics of care and communitarian ethics (Tong, 1998; Beauchamp and Childress, 2001). The ethics of care and communitarian ethics come from different starting points, but what they have in common is recognition that feelings and emotions as well as logical reasoning play a part in decision making, and that the interdependence of people living in families and communities means that no decision can be made in a vacuum without reference to the experiences, values, needs and desires of others. Again in every day life we make decisions by reference to others close to us. Faced with a decision whether to offer further treatment to a child with little chance of survival, we might agree a rule that scarce health resources are to be directed to treatments based on clinical need (a deontological approach). We might also agree that no substantial benefit is likely to be gained by offering the treatment (consequentialist approach). Nevertheless when faced with a desperate child and parents we might be tempted to make the treatment available because of our emotional urge to do all that is possible for the child.
An ethics of care or communitarian ethics approach does not so much provide guidelines as to how we should make decisions, but rather reminds us that rational thinking and rule based approaches are not sufficient in themselves to guide ethical decision-making. An ethical framework should incorporate both respect and empathy for other persons who live within our networks of responsibility, and respect for the value of harmonious relations within the community.
All approaches have their strengths and weaknesses which have been adequately examined and critiqued elsewhere (Beauchamp and Childress, 2001). No approach by itself can explain or justify what makes an act or policy good or bad, right or wrong. Yet both in the private and the public context all three approaches reflect the way decisions are made, and the way in which we determine the worth of those decisions. An overarching ethical framework for public health will need to recognise all three approaches if it is to have application across the range of complex and sensitive issues for which public health has responsibility.
6. 1 Some Absolute Public Health Values
A starting point might be to identify, in recognition of a deontological approach, the minimum content of an ethical framework, a set of universal principles which are absolute and which we would not be prepared to derogate from regardless of the benefit to be obtained. Some fundamental human rights articulated in the Universal Declaration of Human Rights might fall into this category. We might for example agree that no person shall be tortured, even if the purpose of torture is to force him to reveal the whereabouts of anthrax intended for bioterrorism. We might also choose to accept that ‘Everyone has the right to a standard of living adequate for the health and well-being of himself and his family …’[22] .
Some fundamental universal values might also be agreed, which are to be regarded as trumps (Dworkin, 1977) whenever they come into conflict with other values. The American Public Health Association (2002) has suggested some such values in the form of ‘assumptions inherent to a public health perspective’. These include the value of scientific integrity, and the value of knowledge and the moral obligation to share knowledge. We might want to include values fundamental to some other codes of ethics of medical practice, such as respect for humanity, sincerity and compassion[23] , consistency in words and actions, and a guiding principle of conscience (Pang, 1998). We could include some basic principles of philosophical ethics like beneficence (the duty to do good wherever possible) and maleficence (the duty not to cause harm where it is avoidable). Some more general ethical values might include honesty and accountability (Nolan Committee, 1995), as well as truthfulness, protectiveness and nurturing.
6.2 Some Guiding Public Health Principles
Once these fundamental, absolute values have been agreed, then some subsidiary guiding principles would be useful. These guiding principles, which recognise consequentialist and contextual approaches to ethics, will always be subject to the fundamental principles and values and cannot be used to override them. The guidelines should always be given serious consideration in the formulation of any public health policy or intervention, but professional judgment and discretion will dictate how the principles are applied, taking into account a balancing of consequences as well as responsibilities and relationships within the community group affected.
One such principle might be that ‘public health should achieve community health in a way that respects the rights of individuals’ (APHA, 2002). This is weaker than principles of autonomy, informed consent and confidentiality which ‘are paramount’ (MRC, 2002) in codes of medical ethics, bioethics and research ethics. Individual rights must be respected, but where greater public good will result, some non-fundamental individual rights may be overridden. However no public health decision should be made without taking into account, and according respect to, individual rights, and where the public health objective can be achieved in another way which is less invasive, that alternative route should be taken.
To assist in recognition of rights, we might include principles which guide risk allocation, such as a principle that public health polices and programmes should attempt to ensure that the benefits and burdens are distributed in accordance with principles of proportionality (Sachs, 1998; Nhlapo ,1998). Where a public health intervention requires interference with the rights of an individual, the intervention would only be justified to the extent that it is likely to add significantly to the health of the community relative to the invasion of rights. Interventions such as water fluoridation and vaccination for herd immunity should recognise a proportionality approach.
A compulsory vaccination programme for example should take into account risks of vaccine damage (physical, psychological and cultural) in proportion to risks of harm from the disease and likelihood of contraction of disease. Thus any interference with individual rights must be the least invasive and most conservative means of containing the spread of disease. The intervention must be proven to be effective and not speculative, and the disease must be one which causes serious harm and which is highly contagious. The higher the levels of immunity in the community, the less ethical it would be to override individual beliefs and choices against vaccination (Hodges, Svoboda and Van Howe, 2002).
Some common public health interventions such as anonymised HIV testing of pregnant women on an ‘opt-out’ basis, which is cost-effective and facilitates the collection of prevalence figures but denies pregnant women knowledge of the test results (Zulueta, 2000), might need reassessment if such a principle were to govern interventions. Similarly contact tracing for contagious disease in high risk settings where all members of the community are at risk of exposure, or where notification of exposure does not necessarily lead to treatment, is questionable on proportionality principles (Kass and Gielen, 1998). Disease surveillance, an essential tool in combating spread of disease, must also operate subject to proportionality with invasions to personal privacy. While a consequentialist approach might support the collation of all available information on those exposed to disease, respect for rights and the ethics of care would constrain surveillance to that information which can be demonstrated significantly to contribute to the public good in proportion to the harm which might result from invasion of privacy.
The principle of proportionality can be a useful guideline where risks can be scientifically assessed. Where risk is uncertain, such as in the case of GM food or emerging contagious diseases like BSE, we might be assisted by the precautionary principle[24] advocated by the European Court of Justice in relation to anticipatory risks. While it is clearly necessary to take precautionary measures in face of a serious, immediate and unknown threat to the health of the public such as SARS, the ECJ has made clear that states should not invoke precaution to counter risks that are insignificant in terms of seriousness of harm in conjunction with likelihood of occurrence[25] .
Another suggested principle for our framework is that public health policies and interventions should be determined wherever possible through processes that ensure an opportunity for input from community members (Beauchamp and Steinbock, 1999; APHA, 2002). Such a principle would recognise communitarian ethics, while at the same time reflecting, in accordance with a consequentialist approach, that community negotiated programmes work more effectively than imposed policies and interventions.
We also need principles recognising the obligation to rectify health inequalities. Although this should be a strong guiding principle it cannot be a fundamental principle because it will often involve trade-offs with other principles (such as the principle of community involvement when the community majority prefers an intervention which disadvantages a minority group) and with other social goods (priority in allocation of resources).
These principles are suggested as a starting point for the formulation of an ethical framework. Other principles may emerge in recognition of the public health concerns of risk, justice and community. Such a framework should contain both inviolable fundamental principles and values, and subsidiary guidelines which recognise the whole picture in the context of application. Any principles included in the framework must be agreed by all those responsible for public health as the minimum content of such a framework.
7. Will it be Possible to Formulate a Global Framework of Public Health Ethics?
If one of the objectives of our public health framework is to facilitate global dialogue and information exchange in public health, then we must try to formulate some universally agreed norms which reflect shared assumptions of public health objectives and mechanisms. Seeking agreement of universal norms has not proved easy in the context of human rights. Attempts to develop a global code of bioethics have faltered partly because early formulations of such a code have been based on human rights jurisprudence[26] even though it has been recognised that a universal code of bioethics is needed to underpin the integrity and validity of medical scientific research[27] . Bioethics is also difficult to regulate because of the potential for economic advantage from medical scientific research. We need to avoid the political dimension of human rights debates in our formulation, and focus instead on a minimum content of standards and responsibilities within a shared focus of public health concerns and objectives. It is this shared focus which should make our task easier.
For all the differences in economic, historical and cultural development across states, there is significant commonality in their public health systems.
All states would support the creation of an ethical environment for health care[28] , even if they might not agree on the shape of that environment.
All states would agree that there is both collective and individual responsibility for health care even if they might disagree as to allocation of those responsibilities.
All public health systems start from the same premises of doing good, trying not to cause harms, and valuing (in the theory at least) honesty, scientific integrity, truthfulness and respect, even if they might disagree about the relative weight of these virtues.
All public health systems would aim to abide by fundamental universal human rights even if they might argue about some social, cultural and economic rights.
All public health systems would consider themselves to have responsibility for both the population as a whole and the communities and individuals within that population even if they might take a different stance on notions of personhood or autonomy and their relationships with the community.
All public health systems face similar problems such as disease, ageing populations, scarcity of health resources, poverty and consumer demands, though different states will face these problems to a different degree.
All public health systems must concern themselves with both a positive obligation to create a healthy environment (health prevention, promotion and education) as well as an obligation to combat existing ill health, although the priorities given to these activities will differ according to the levels of existing ill health.
All public health systems must co-ordinate with, and be constrained by, other public and private bodies such as those responsible for development, finance, agriculture, animal husbandry, food, education, housing, public works, communications and the media.
All public health systems must undertake unpopular tasks which infringe the rights and privacy of individual citizens, such as surveillance, coercion and advocacy, although states may differ in the extent to which they feel justified in these interventions.
Given such commonality, an agreed global framework is not out of the question. A natural starting point would be for individual states to draft their own public health codes or frameworks, and for these to be drawn together to identify common denominators. In recognition of the principles of community involvement, a ‘bottom up’ process of formulation would far more effectively reflect the essential, minimum content of an agreed framework than a code of ethics imposed by the WHO or borrowed from US public health jurisprudence.
It is the emergence of SARS which has made clear the necessity of an ethical framework to public health to assist in the preparation of response to emerging and serious global public health threats. Several particular ethical dilemmas arising from SARS can be identified.
The speed, seriousness and mystery of the SARS virus resulted in a distorted perspective of the disease in relation to other public health threats, at individual, public, institutional and state level. It is clear that more needs to be done on the communication and understanding of relative risk. Public health authorities will need to develop communication skills to educate the public to differentiate between levels of risk, and the media needs education on responsibility for the portrayal of risk.
Partly in response to public demand, significant public health resources are being allocated in preparedness for re-emergence of SARS, resources taken from other public health programmes. The public might call for full protection at any cost, and the jobs and reputations of politicians and health workers might be on the line were SARS to re-emerge and result in fatalities. But to counter a possible return of SARS may well means that TB or AIDS programmes are under-resourced and a silent group of sufferers will die unnoticed by the media and so by the public[29] . At the same time, it might be argued that the public health measures taken to counteract SARS (distribution of masks, education in cleanliness, influenza vaccination,[30] advice to persons suffering symptoms of coughs and fever) serve both directly to counter public fears and indirectly to reduce other public health threats (influenza, meningitis, TB), and so are justified on a consequentialist analysis.
How can ethics help in determining how to deal with resource issues and SARS? Fundamental principles such as the right to life, compassion and humanity would ensure that all persons who had contracted SARS were provided with the necessary medical treatment, but to what extent should resources be devoted to health protection? The views of the community (full commitment at any cost) should be heard, but there is also an obligation to involve the public in a calculated risk assessment which takes into account principles of proportionality and precaution. A consequentialist examination would recognise that prevention measures against SARS will achieve other public health goods which can be weighed against the harms caused by reallocation of resources. At the same time if particular groups (health workers, people living in housing estates with poor standard of services) can be identified as more vulnerable to contagion then principles of justice might support a focus of resources on those groups. Final assessments on health protection measures in the face of SARS will differ from context to context, but compliance with principles of ethics will enable understanding of public health decisions and facilitate the coordination of a global response to a global problem.
Another ethical dilemma arising from SARS has been the employment position of health workers. Should a doctor or nurse be obliged to treat a SARS patient or should the choice be left to the individual worker (Sibbald 2003b)? Patients need to be treated both for their own benefit and for the benefit of the public. Health workers have been put at considerable risk, and a significant proportion of SARS fatalities were among health workers[31] . Some state laws give employees the right to refuse to work in dangerous conditions[32] . Under the UK Health and Safety at Work Act 1974, an employer has a duty to conduct the workplace in such a way ‘as to ensure, as far as is reasonably practicable, the health, safety and welfare of all his employees.’[33] An employee has a duty ‘to take reasonable care for the health and safety of himself …’[34] but there is no right to refuse to work. Some professional codes of practice do allow for refusal to work in some circumstances. The Nursing and Midwifery Council Code of Professional Practice 2002 allows workers covered by the Code to object in advance to undertaking forms of treatment or care to which they have conscientious objection, but makes clear that the worker must continue to provide care until alternative arrangements are implemented.[35] Is there a danger ‘threshold beyond which health care workers aren’t obliged to take personal risks?’[36] The determination of responsibilities and duties in relation to treatment of individual patients is a matter for codes of medical ethics and professional practice, but any code of public health ethics must also address the public health risks faced by those involved in the provision of public health services.
The WHO has identified a range of other concerns resulting from SARS, including ‘the power of a poorly understood new infectious disease to incite widespread public anxiety’, ‘great social unease, economic losses, and some political changes’, and ‘unwarranted discrimination’ (WHO, 2003). Many of these problems resulted from lack of truthfulness and transparency in reporting, as well as a failure properly to assess and communicate risk. None of these problems is a necessary consequence of SARS. A common, agreed ethical framework of public health response would go a long way to avoiding such concerns.
SARS has prompted a rethinking of the way in which public health services operate, not only in states immediately affected by the virus such as Canada[37] and Hong Kong, but across the world. ‘The clear capacity (of SARS) for spread along the routes of international air travel’ (WHO, 2003) has alerted all states to their vulnerability to new infectious diseases. SARS has also ‘challenged WHO to set in motion high-level international scientific and medical collaboration in which natural competition for publication and prestige is set aside in the interest of solving the scientific mysteries of a shared threat.’ (WHO, 2003).
Lessons have been learned from SARS, but it must be remembered that SARS is only one of many emerging and re-emerging threats to public health at global level. A global response to such threats rests on transparency and trust across states, and transparency and trust can only be achieved on the basis of shared understandings of public health goals and constraints. Negotiation and debate in a forum where all states (and representative non-governmental organisations) are represented would be the most valid means of formulating a global code or framework of public health ethics but might be difficult to achieve. An alternative approach would be to start with formulation of ethical public health frameworks within nation states, in the hope that a common denominator of ethical public health practice across states can be identified. It is on the basis of these individual frameworks that a global code will hopefully emerge.
Endnotes
[1] The Department of Health website highlights two public health issues on its lead page: SARS and MMR. More significant public health threats within the UK such as TB and HIV/AIDS are not highlighted. See: <http://www.doh.gov.uk/>
[2] The WHO reports that of 26 September 2003, 8098 persons were likely to have contracted SARS, and in the case of 774 persons death was attributed to SARS. <http://www.who.int.csr/sars/country/table> The WHO has identified TB, HIV and malaria as the most worrying infectious diseases, killing approximately 5 million persons per year.
[3] Reports suggest that 11,400 persons died in France as a consequence of ‘la canicule’. See: <http://www.lexpansion.com/art/15.357.0.0.html>
[4] ‘The terror of unknown is seldom better displayed than by the response of a population to the appearance of an epidemic, particularly when the epidemic strikes without cause.’ (Kass, 1997 cited in Lee, A, 2003).
[5] Hsieh (2003) argues that public health professionals in Taiwan had to rely solely on internet information because of Taiwan’s exclusion from the WHO.
[6] The speedy detection of the first cases in South Africa and India resulted from information shared on electronic databases.
[7] In Singapore the Infectious Disease Act Cap 137 was amended to classify SARS as a Dangerous Infectious Disease, with the effect that broad powers of notification, detention and quarantine came into effect. A new section 21A imposed duties on individuals who may have come into contact with the disease, breach of which give rise to an offence. Surveillance measures included electronic tagging and video cameras, and enforcement was assisted by military forces.
[8] Hong Kong made SARS a notifiable disease under the Quarantine and Prevention of Disease Ordinance Cap 141 and the Prevention and Spread of Infectious Disease Regulations. Many other states not threatened by the 2003 SARS outbreak also made SARS notifiable, e.g. India, New Zealand and Australia.
[9] UK has so far not made SARS notifiable under the Public Health (Control of Disease) Act 1984, despite calls to do so from the Shadow Health Secretary. In a question to the House of Commons on 11 June 2003, Ms Blears on behalf of the government replied that ‘Based on information from the WHO, the Chief Medical Officer recommended that making SARS a notifiable disease from the outset would slow down the reporting of probable cases at a critical time. Moreover there was nothing to suggest that people with possible SARS or their contacts would set out to reject medical help and advice and thus require compulsory detention.’ The Health Protection Agency (HPA, 2003) has published a discussion paper on notification. Considerations include that the symptoms of SARS are obvious and devastating such that persons who had contracted the disease would be clearly identified without a formal notification procedure, while diagnostic tests for those exposed to disease were not sufficiently accurate to warrant notification. As the Public Health Act 1984 currently makes no provision for quarantine of persons exposed to disease (as distinct from detention of persons with disease who are non-compliant with treatment) and makes no provision for compulsory medical treatment, new legislation would be required to provide for control of exposed persons. Nevertheless the Health Protection Agency does provide forms for doctors to report possible cases of SARS (HPA CDSC SARS Surveillance Reporting Form).
[10] For example France (Da Lomba and Martin, 2003).
[11] The multinational SARS Expert Committee Report (2003) found that if Hong Kong had access to accurate information about the atypical pneumonia outbreak in Guangdong in November 2002, the outbreak in Hong Kong would have been ameliorated.
[12] Forward, International Health Regulations, para 2.
[13] For a detailed analysis of the IHR see Arai 2001.
[14] ‘The concept of progressive realization constitutes a recognition of the fact that full realization of all economic, social and cultural rights will generally not be able to be achieved in a short period of time…[It is] a necessary flexibility device, reflecting the realities of the real world and the difficulties involved for any country in ensuring full realization of economic, social and cultural rights.’ General Comment No 3 (1990): The Nature of States Parties Obligations (Art 2, para 1 of the Covenant), Committee on Economic, Social and Cultural Rights, 5th session, Economic and Social Council, Official Records, 191, Supplement No 3, Annex III, E/1991/23, E/C12/1990/8, paras 1-2
[15] For example the Convention Relating to the Status of Refugees 1951, the Convention on the Protection of the Rights of All Migrant Workers and their Families 1990 and the Convention on the Elimination of All forms of Discrimination against Women 1979.
[16] Some human rights treaties specifically allow restrictions on private rights for the protection of public health. For example Article 5 of the European Convention on Human Rights, dealing with the right to liberty and security, provides an exception for prevention of the spread of infectious diseases. Article 8 of that Convention (right to respect for private and family life) provides exceptions for the protection of health. Similarly Article 4 of the the International Covenant on Economic, Social and Cultural Rights implies that public health grounds would justify a restriction on rights, as do Articles 19(3)(b) and 21 of the Covenant on Civil and Political Rights.
[17] WHO notes that ‘ … in a globalized, electronically connected world, attempts to conceal cases of infectious disease, for fear of social and economic consequences, must be recognized as a short-term stop-gap measure that carries a very high price – loss of credibility in they eyes of the international community, escalating negative economic impact, damage to health and economies of neighbouring countries, and a very real risk that outbreaks within the country’s own territory can spiral out of control.’ (WHO 2003)
[18] The Public Health Act 1984 (UK) imposes fines for a range of offences including knowingly exposing others to the risk of tuberculosis, or exposing others to infected clothing or bedding (s. 17), carrying on a trade or business where there is a risk of disease spread (s. 19) or placing infected materials in a rubbish bin (s 26).
[19] Bowling (1996) suggests there is public support for rationing NHS resources where patients can be said to have contributed to their own illness. This is controversial (Beecham 1994).
[20] For example the NHS Executive (NHS Executive 1999, p 65) advice on public health refers readers to commentary on medical ethics.
[21] In Roe v Lancashire HA 8 March 1985, unreported, a case concerning allocation of responsibility for contraction of tuberculosis, Russell J took into account in his judgment that ‘…it had to be recognised that the immigrant patient, in his personal habits of hygiene, tended to be less inhibited than his indigenous counterpart.’
[22] Article 25 Universal Declaration of Human Rights. See also Art 12 of the International Convention on Economic, Social and Cultural Rights.
[23] As reflected in The Yellow Emperor’s Classic of Internal Medicine (400BC – 240 BC China) and the Chinese Hippocratic Oath (Qiu, 1992).
[24] ‘…a principle which permits precautionary action (regulation) to prevent an uncertain or future risk in advance of complete evidence about risk’, Bergen Ministerial Declaration on Sustainable Development in the ECE Region, Yearbook of International Environmental Law 1990 (Wiener 2003)
[25] Commission of the European Communities v French Republic (Failure of a Member State to fulfil its obligations – Refusal to end the ban on British beef and veal) (2000) ECR I-09989 (ECJ 2001). In Monsanto Agricoltura Italia SpA v Presidenza del Consiglio dei Ministri, Case C-157/96, judgement of 9 September 2003 (on GMOs), the ECJ held that in a case where there is uncertainty as to the existence or extent of risks to human health, protective measures can be taken without waiting for the seriousness of those risks to become fully apparent. See also The Queen v Ministry of Agriculture, Food and Fisheries, Commissioner of Customs and Excise, ex parte National Farmers’ Union et al [1998] ECR 1-2211 and UK v Commission [1998] ECR 1-2265
[26] For example the Convention sur les droits de l’homme et la biomédecine, signed at Oviedo (Spain) 4 April 1997
[27]See ‘Jaques Chirac souligne l’urgence d’un code universel de bioéthique’, Le Monde 15 October 2003.
[28] Art 12 ICESCR provides that ‘States …recognise the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’. See UN Doc. E/C.12/2000/4, General Comment No 14: the right to the highest attainable standard of health, 4 July 2000
[29] Sibbald (2003a) argues that during the SARS outbreak, four times as many people in Ontario would die from lack of medical attention caused by SARS, as would die from SARS itself.
[30] WHO (2003) suggests that vaccination of vulnerable persons (such as the elderly) against influenza may lower the number of influenza cases which raise suspicion of SARS, and so help with SARS surveillance.
[31] In Hong Kong, 379 health workers developed SARS, and three of them, one doctor, one nurse and one healthcare attendant, died. (Lee S 2003). Nurses were particularly at risk (Chan 2003, McGillis Hall, Angus et al 2003)
[32] Occupational Health and Safety Act, Ontario allows workers to refuse to work when the physical condition of the workplace is likely to endanger the worker. (Sibbald 2003b)
[33] Section 2 (1)
[34] Section 7
[35] Clause 2.5
[36] Dr Peter Singer, Director of the University of Toronto Joint Centre for Bioethics, quoted by Sibbald 2003b.
[37] It has been noted that ‘In Canada, the SARS crisis has led to a drastic rethinking involving Canada’s public health network.’ (Nadamuni 2003)
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