Ethics Briefing for Covid19 Policy: Interesting Experience in Germany and a Plea for the Swedish Context

As the Covid19 pandemic continues to sweep the world, states are struggling to shape policies according to their epidemiological situation, resources and political possibilities. It is very obvious that all this policy-making has far-reaching ethical implications on many levels. It regards the identification of relevant values, the balancing of these in cases of conflicts, the pragmatics of implementing "ideal" solutions in a non-ideal world, and the normative aspect of deciding how competing institutional "rules" or "guidelines" for balancing values and implementing the outcome may be traded off in cases of tension.

All of this is, of course, a well-known aspect of the area of public health ethics, such as it has evolved over the last two decades. It regards both principal issues of what should be done, and issues about how this should be done to be done in an acceptable way. These issues are especially complicated due to the multi-sectorial and multi-level nature of public health, and the advanced and dynamic uncertainty under which all decisions on pandemic (and much other public health) policy needs to be taken.

One level is, of course, the implications for the healthcare system and, in effect, clinical medical ethics, of a far-reaching public health crisis, such as a pandemic. In this area, I was engaged, together with several colleagues with direct experience of this particular issue, in a working party that speed developed specific guidelines for ICU resource allocation for the Swedish context. However, albeit thorny and highly complex ethical considerations are recognised to be built into both public health and infectious disease policy in the Swedish central policy document in this area, the Swedish public health authorities have no organised way of dealing with the ethical tensions that necessarily appear on a daily basis. This inspired some of my colleagues – themselves not public health ethicists but recognising the need – to publish a plea for an ethics councel function  to be linked to the Swedish public health agency, Folkhälsomyndigheten. Such a councel has to involve different comnpetences, of course, besides public health ethics and relevant health science, not least advanced knowledge of (relevant) law, economics and politics.

Interestingly, I have been recently involved in exactly this type of endeavour related to Covid19, not in Sweden, but in Germany. It started when I was contacted, as one of several public health ethics specialists, to be part of an ad hoc ethics briefing to the Bavarian public health authorities with regard to sevaral of the type of basic value and norm.-conflicts briefly sketched above. The work was led from the Ludwig Maximilians University of Munich, where Verina Wild (bioethicist and public health specialist), quickly organised an international expert group to answer a set of questions formulated by the state authorities. This work (with links to the full briefing from the group to the Bavarian authorities) is described here. Additionally, the German federal Ethikrat has issued several statements on the ethical dimensions of the Covid19 policy response, and also there specific public health ethical competence is in place, eg. Alena Buyx.

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In addition, German scholarly organisations in social medicine and public health have organised a Covid19 "competence centre" with specific working groups being coordinated for several areas, one of which is ethics. The coordinators for ethics is, once again, Verina Wild and her Munich colleagues Jan-Christoph Heilinger and Georg Marckmann, and they have invited a broad group of international scholars from the public health ethics field, among these myself. We have just finalised the first policy brief, which attempts to sketch in a few pages the complex landscape of consideration offered from a public health ethical perspective on pandemic policy. The final versionis now public via the competence centre website. A number of more specific briefs are planned, and will appear shortly.

I do believe that many states would do well to follow the German example. Besides the expertise of discovering, describing and analysing ethical and related legal and political dilemmas, relevant scholars are also able to articulate more clearly the logic of reasoning behind made policy decisions, thereby helping governments and agencies to better dodge conspiracy-like speculations of why certain decisions are made due to hazy explanations and arguments.  Among these, my own country Sweden, where there already exist a number of internationally recognized public health ethics scholars, besides myself, e.g., Bengt Brülde, Jessica Nihlén Fahlqvist, Kalle Grill and Erik Malmqvist, and additional legal scholarly expertise relating to the health policy area, such as Moa Kindström Dahlin and Ulrika Sandén.

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Awesome Resource for Public Health Ethics Scholarship and Training Available Online for Free!

Yes indeed! Super kudos to the editorial team of Drue H. Barrett, Leonard H. Ortmann, Angus Dawson, Carla Saenz, Andreas Reis and Gail Bolan – and the sponsor CDC – for putting together this freely available, pioneering and one of a kind collection of case studies and background texts for global public health ethics study, research and training. With contribution by a pack of high octane scholars, such as Ruth Gaare Bernheim, Jo A. Valentine, Lisa M. Lee , Kayte Spector-Bagdady, Maneesha Sakhuja, Norman Daniels, Michael J. Selgelid, Janani Suraksha Yojana, Harald Schmidt, Bruce Jennings, Anthony Wrigley, Eric M. Meslin, Ibrahim Garba, Natalie Brown and Barbara R. DeCausey. 

Available for free download as PDF wherever you are. Just go here.

New Cross-disciplinary Antiobiotic Resistance Research Centre at my University

Yesterday, I received the delightful news that a big bid, in which I am one of several co-applicants, to establish a centre for research, education, innovation and change in the area of antibiotic resistance research, CARe at my university has been awarded a more than €5 million base funding for the coming 6-7 years in an internal university competition called the UGot Challenges, that's been going on for about 2 years.

The lead applicants of CARe are Joakim Larsson, professor of environmental biomedicine, and Fredrik Carlsson, professor of environmental and behavioural economics, and the co-applicants involve many senior researchers from the medical field, industry and societal collaborators, and several social scientists and humanities scholars, in the latter case, also my departmental colleagues philosophy professor Bengt Brülde and theory of science senior professor Margareta Hallberg. The aim of the centre is thus outspokenly and strongly cross-disciplinary, involving 6 faculties, acknowledging the challenge of antibiotic resistance, like many other broad challenges such as climate change, to involve many crucial aspects beyond those covered by natural and medical science and technology development. The primary scientific and technological target of CARe will moreover be what is presently considered as the last straw and stage of antibiotics to fight multi-resistant bacteria, so-called carbapenems, the development and use of which, of course, imply a large number of complex ethical issues, e.g. with regard to the need for highly restricted prescription in order not to boost further the current destructive trend in resistance development among bacteria, or exceptional need for haste in introducing new substances in spite of knowledge gaps or uncertainties.

Here is the official announcement from the university:

UGOT Challenges information (English)

Stage 2 decision
The university Vice-Chancellor has made the decision on the outcome of UGOT Challenges Stage 21 based on external evaluation. All 12 groups that were invited to stage 2 submitted a proposal before the deadline. 6 of the proposals have been approved.

Approved proposals
Centre for Antibiotic Resistance Research at University of Gothenburg. Joakim Larsson and Fredrik Carlsson
Centre for Collective Action Research. Sverker C Jagers and Sam Dupont
The Swedish Mariculture Research Center at University of Gothenburg. Kristina Sundell
Centre for Ageing and Health – studies on capability in ageing – from genes to society. Ingmar Skoog
Center for Critical Heritage Studies. Kristian Kristiansen and Ola Wetterberg
Centre for Future Chemical Risk Assessment and Management Strategies at the University of Gothenburg. Thomas Backhaus and Jessica Coria

Documents supporting the decision are available at www.gu.se/ugotchallenges.
The host departments have been assigned to submit a formal application to establish the centres in early 2016. When funding has been granted for an existing centre the operational plan should be updated.

About UGOT Challenges
University of Gothenburg will invest 300 million SEK in research under the theme "global societal challenges" over the next years. The aim is that a number of new centres will be started from 2016.

Now Online: Special Symposium of Public Health Ethics: New Media, Risky Behaviour and Children

All good to those who wait, it's said, and in this case this certainly holds up to scrutiny...

 

Yesterday afternoon, a special symposium in this year's first issue of the journal Public Health Ethics, guest-edited by myself and my colleague Karl Persson de Fine Licht, on the topic of New Media, Risky Behaviour and Children, went online after about 2 years of work, starting with this call for papers. In addition, the call came out of a preceding European project, running 2011-12, taking off as an original idea at a workshop we held in Gothenburg in October 2011. We are, of course, mighty grateful to the PHE editors-in-chief duo of Angus Dawson and Marcel Verweij, who accepted our proposal, remained committed to it and has offered all support needed under way.

The full table of content looks like this:

Introduction 
Christian Munthe and Karl Persson de Fine Licht
Editorial: New Media and Risky Behavior of Children and Young People: Ethics and Policy Implications. Introducing the Themes and Pushing for More 

Original articles
Julika Loss, Verena Lindacher, and Janina Curbach
Do Social Networking Sites Enhance the Attractiveness of Risky Health Behavior? Impression Management in Adolescents’ Communication on Facebook and its Ethical Implications

Joakim Forsemalm
Consolidated Youth Jury: Alcohol Prevention for Young People from Matters of Fact to Matters of Concern. A Swedish Case Report
  
K. P. Mehta, J. Coveney, P. Ward, and E. Handsley
Parents’ and Children’s Perceptions of the Ethics of Marketing Energy-Dense Nutrient-Poor Foods on the Internet: Implications for Policy to Restrict Children’s Exposure 

Boudewijn de Bruin
Alcohol in the Media and Young People: What Do We Need for Liberal Policy-making?

Case Discussion  

Kate L. Mandeville, Matthew Harris, H. Lucy Thomas, Yimmy Chow, and Claude Seng 

Using Social Networking Sites for Communicable Disease Control: Innovative Contact Tracing or Breach of Confidentiality?

Jasper Littmann and Anthony Kessel 

Accounting for the Costs of Contact Tracing through Social Networks  

André Krom 

From Facebook to Tracebook: A Justified Means to Prevent Infection Risks? 

Mart L. Stein, Babette O. Rump, Mirjam E. E. Kretzschmar, and Jim E. van Steenbergen 

Social Networking Sites as a Tool for Contact Tracing: Urge for Ethical Framework for Normative Guidance

David M. Shaw 

Communicating About Communicable Diseases on Facebook: Whisper, Don’t Shout  

Thomas Ploug and Søren Holm 

Take Not a Musket to Kill a Butterfly—Ensuring the Proportionality of Measures Used in Disease Control on the Internet

Now, I would myself very much have preferred to have the entire issue open access, for anyone to probe, but since that would cost about €1500 / article, and there are 11 articles in the symposium, there was no financially feasible way of managing this. One of the contributions is open access, due to it having been written in a context where funding for that objective has been available, but this is normally not the case for ethicists, social scientists and practitioners – unlike our more wealthy cousins within clinical and laboratory health science, I might add.

For access, your best bet is through a university library, a student or staff at a university with access, or you can try contacting individual authors and/or look around for so-called postprints posted in public archives.

Reproductive Public Health Ethics at MANCEPT 2014

Happy to be able to tell the world that a proposal headed by myself for a series of sessions at the increasingly popular and important MANCEPT Workshops in Political Theory conference has been accepted for this year's edition, September 8-10, 2014.

The proposal is on the theme of Reproductive Public Health Ethics, where a selected lineup of speakers from the Netherlands, Romania, Sweden and the UK will address different dimensions (biopolitics, bioethics, public health ethics, population ethics, environmental ethics) of ethics and value issues attached to reproductive policy. The presenters include, besides my humble self:

Gustaf Arrhenius
Richard Ashcroft
Becky Brown
Krister Bykvist
Daniela Cutas
Angus Dawson
Anca Gheaus
Kalle Grill
Marcel Verweij
Stephen Wilkinson

With a few possible additions to come. More on this as the exact program etc. is set and made public.

Review of The Ethics of Screening in Health Care and Medicine

My and Niklas Juth's new book The Ethics of Screening in Health Care and Medicine: Serving Society or Serving the Patient? is reviewed by Pekka Louhiala in very favourable terms in an essay now published  online by Medicine, Health Care and Philosophy. Alas, it is behind a paywall (unless you or your library has a Springerlink subscription), although you may sample the first page for free. Here, however is the conclusion of it all:

In summary, The Ethics of Screening in Health Care and Medicine is practical philosophy at its best: scientifically well informed, balanced, carefully argued and highly relevant for the practice of medicine and health care.

Reference: Louhiala, P (2012). To screen or not to screen: that is the ethical question. Niklas Juth and Christian Munthe: The ethics of screening in health care and medicine—serving society or serving the patient? International library of ethics, law, and the new medicine, Volume 51. Springer, Berlin, 2012, 175 p, €99.95, ISBN 978-94-007-2044-2. Medicine, Health Care and Philosophy, 15, Online first: DOI: 10.1007/s11019-012-9396-6.

New Book on the Ethics of Screening in Health Care and Medicine

So, once again, some self-promotion, but this time not only, since the new book I'm plugging in this way is the result of a truly collaborative enterprise with Niklas Juth, senior lecturer in medical ethics at the Karolinska Institute. Published by Springer, the title of this book is The Ethics of Screening in Health Care and Medicine: Serving Society or Serving the Patient?

 To quote the summary:

Medical or health-oriented screening programs are amongst the most debated aspects of health care and public health practices in health care and public health ethics, as well as health policy discussions. In spite of this, most treatments of screening in the research literature restrict themselves to isolated scientific aspects, sometimes complemented by economic analyses or loose speculations regarding policy aspects. At the same time, recent advances in medical genetics and technology, as well as a rapidly growing societal focus on public health concerns, inspires an increase in suggested or recently started screening programs.

This book involves an in-depth analysis of the ethical, political and philosophical issues related to health-oriented screening programs. It explores the considerations that arise when heath care interacts with other societal institutions on a large scale, as is the case with screening: What values may be promoted or compromised by screening programs? What conflicts of values do typically arise – both internally and in relation to the goals of health care, on the one hand, and the goals of public health and the general society, on the other? What aspects of screening are relevant for determining whether it should be undertaken or not and how it should be organised in order to remain defensible? What implications does the ethics of screening have for health care ethics as a whole?

These questions are addressed by applying philosophical methods of conceptual analysis, as well as models and theories from moral and political philosophy, medical ethics, and public health ethics, to a large number of ongoing and proposed screening programs which makes this book the first comprehensive work on the ethics of screening. Analyses and suggestions are made that are of potential interest to health care staff, medical researchers, policy makers and the general public.

The book is available for purchase via its homepage, linked to above, and as e-book via its Springerlink page, where there is opportunity to sample the contents, parts of chapters, bibliography and the index. More generous sampling is accessible through Google books. Note, that if you are a student, academic, health care professional or official or policy maker, it may very well be the case that you can access a free e-book copy through a library (e.g., your university library) that subscribes to Springerlink!