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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Registration Open for Our Free of Charge Symposium on Ethics and Antibiotic Resistance!

As I reported before, the Centre for Antibiotic Resistance Research, CARe, at the University of Gothenburg, is organising a free of charge symposium this fall on the theme of Ethics and Value Challenges in Antibiotic Resistance Management, Policy and Research.

Participation is free and open to professionals, officials, policy makers, researchers and interested members of the public, but requires pre-registration. Get more information and sign up here.

Taking place November 15-16, this is a unique opportunity for anyone interested in the topic of antibiotic resistance to learn from and interact with world-leading researchers in this area, representing disciplines such as bioethics, law, medicine, philosophy and public health, including Michael Selgelid, Clare Chandler, Marcel Verweij, Alena Buyx, Jonathan Anomaly, Steven J. Hoffman, Julian Savulescu, Otto Cars, and others.

Below is a flyer for the event - please share it as much as you like!

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.

Reproductive Public Health Ethics at the MANCEPT Workshops in Political Theory, 2014.

In a few hours, I'm off to Manchester, UK, for participation in a so-called panel ( ≈ special symposium) at the MANCEPT Workshops in Political Theory 2014. The panel is on the topic of Reproductive Public Health Ethics and has been conceived of and convened by myself. The topic itself is described thus, at the Mancept website:

Human reproduction and resulting population patterns is a classic concern of public policy, yet philosophical and ethical applications to this area remain imprecise, scattered and unsystematic. The point of this workshop is to stimulate a more integrated addressing of this area for social and political philosophical analysis from a public health standpoint. Reproductive bioethics hosts established interest in the regulation of reproductive technology, yet mostly ignoring overarching societal concerns to the benefit of a discourse focusing on individual reproductive liberty. This individualism has stimulated the emergence of public health ethics, where queries regarding health policy are put at a population level, but reproduction- and population issues have not been in focus, partly due to a common conflation in public health between reproductive and sexual health. In parallel, biopolitics subjects cultural layers of policy to critical scrutiny regarding “identities” and concepts central to laws across the world – e.g. parenthood and family – in light of, e.g., technological developments. Also here, public health ethical perspectives are scant, while dimensions of justice otherwise often ignored are addressed, making possible, e.g., explorations of hidden presumtions behind reproductive policies. More basic research on population ethics, while having somewhat informed reproductive bioethics, remains largely unexplored as to more conrete political and policy implications in either of the mentioned dimensions, e.g. in the face of environmental challenges and expected consequences in the form of resource scarcity and global migration. There are also theoretical conundrums which need attention, e.g. how justice-oriented discourses of biopolitics can be squared with the intricate problems of population ethics, or how the combination of these and a globalised public health ethical approach relates to the individualist assumptions of reproductive bioethics. The workshop assembles a selected group of presenters from the Netherlands, Romania, Sweden and the UK.

The same website also lists an, alas, not so up to date speaker list, as I've had a few cancellations and a few new people entering the program since it was initially presented to the Mancept organisation. The actual program looks like this:

• Session 1: Sept 8, 2 PM - 5:30 PM

Christian Munthe, University of Gothenburg: Reproductive Population Health and the Goals of Public Health: Exploring a Territory of Moral Unease

Angus Dawson, University of Birmingham: Public Health Reproduction: Defending the Very Idea

• Session 2: Sept 9, 9:30 AM - 1 PM

Daniela Cutas, Umeå University & University of Gothenburg: The Nuclear Family and Reproductive Policy: Ethical Challenges

Marian Verkerk, University of Groningen & Ulrik Kihlbom, Uppsala University: Preconception Genetic Testing and Reproductive Counselling as Challenge to the Family as Social Institution

Anca Gheaus, Sheffield University: Biological Parenthood: Gestational not Genetic – Implications for Reproductive and Family Law

• Session 3: Sept 9, 2 PM - 5:30 PM

Stephen Wilkinson, Lancaster University: The Public Health Ethics of Selecting Future Children

Anna Smajdor, University of East Anglia: Postponed Motherhood and the State

Rebecca Brown, University of Aberdeen: Incentives for Reproductive Public Health

• Session 4: Sept 10, 9:30 AM - 1 PM

Kalle Grill, Umeå University: Population Policy in the Face of Environmental Challenge: What Place for Reproductive Liberty?

General discussion on future developments and prospects of the topic in forthcoming endeavours


If you happen to be at the Mancept Workshops event, please don't hesitate to drop in on our panel, or approach about interest in the general topic!

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.

Will Sweden Withstand the Planned EU Tobacco Directive Rules on Cigarette Packet Warning Labels?

News just broke that the current Swedish government is planning to try to resist the planned implementation of a new EU tobacco directive application according to which cigarette packets must have warning labels covering 75% of the packet's surface space. Why on earth would the government of one of the world's top non- and anti-smoking and pro public health countries in this way want to do the tobacco industry's dirty business for them, one might ask. But according to the government, this matter is nothing of the sort. The reason given for why the government plans to resist the proposal is that it allegedly in conflict with the Swedish constitution, more specifically The Freedom of the Press Act (FoP, the original Swedish version of the act, Tryckfrihetsförordningen, or TF, can be read here).

I suppose that what the government think is problematic with regard to the EU tobacco directive proposal in relation to this, is the very strong ban on censorship in the FoP and a very tightly regulated possibility to prosecute for misuse, expressed in the first four articles of the 1st chapter of FoP. However, I very much doubt that any of these generous liberties can be convinsingly argued to apply to cigarette packets. First, altready in article 5, the scope of the act is defined to apply...

...provided:
1.    a valid certificate of no legal impediment to publication exists in respect of the written matter; or
2.    the written matter is supplied with a note indicating that it has been duplicated and, in association therewith, clear information concerning the identity of the person who duplicated it and the year and place of duplication.

Most cigarette packets will be excluded already st this stage. However, tobacco companies may of course come to have the packets designed so that this condition is met. This will not help the argument of the government much, however, for in article 6 the scope of the act is further limited with regard to what written or printed matter it regulates:

Printed matter shall not be deemed to be such unless it is published. Printed matter is deemed to have been published when it has been delivered for sale or dissemination by other means within the Realm. This does not however apply to printed documents of a public authority to which there is no public access.

Are cigarette packets published?, one may ask. Well they are produced through printing and then publicly offered, aren't they? Well, incidentally they are, but they are surely not sold or otherwise disseminated in the sense intended in the law. First, what is sold are the cigarettes, the packet is a container that is not for sale, albeit accompanying the sold product. We could, of course, imagine tobacco companies try to claim that it is the packet that is the product, and that the cigarettes are just an incidental appendice. However, I hardly think that such a move would exempt them from paying tax on tobacco sales. Therefore, the packet is not what is sold. Neither is it disseminated, since that would imply, e.g., that the address label attached to or any sort of scribbling on a packet of newspapers, books et cetera would be protected by the FoP. Surely they are not.

However, I need not rest my case on that argument alone, for if we continue reading, we come to the crucial article 9, wehre it is said that....

The provisions of this Act notwithstanding, rules laid down in law shall govern:
1. bans on commercial advertising insofar as the advertisement is employed in the marketing of alcoholic beverages or tobacco products; /.../

3. bans on commercial advertising introduced for the protection of health or the environment in accordance with obligations pursuant to accession to the European Communities;

What this implies is that as long as the cigarette packets qualify as either "marketting of .... tobacco products" or "commercial advertisement", FoP readily allow either any sort of censoring ban to be applied, or allow such a ban "for the protection of health or the environment in accordance with obligations pursuant to accession to the European Communities". What was this all about again, please? The European Union tobacco directive?? Uh Oh!

Now, I may have gotten all of this terribly wrong and perhaps there is a nice government memo somewhere describing a superb argument for why the EU tobacco directive regulation regarding warning text on cigarette packets is unconstitutional in Sweden. More likely, however, is that if such a memo ever existed it is fundamentally flawed and very possibly a product of sloppy analysis, and will soon find itself crumbling in the waste paper basket of the responsible minister's office. My own proposal is that said minister should inquire his/her legal advisors closely of however they could come up with such folly, and maybe take the opportunity to ask a question or two about their links to the tobacco industry as well.

So, what was the other hypothesis? That the Swedish government is doing the dirty business of tobacco companies for them? It can't be can it?! Especially not since the second argument of the government is that these companies will only have 25% left of the surface space of packets to expose their brand markings. Truly, truly poor them little innocent ones being so unjustly attacked by the vile European Commission!! So it is definitely not a question about that at least - phew!

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!