Public Health Ethics. Thinking about bioethics, human rights, justice and moral responsibility

Summary

This video script delves into the multifaceted realm of public health ethics, categorizing ethical considerations into four domains: individual, group, national, and global perspectives. It explores principles like bioethics, human rights, and the philosophical debates between deontological and utilitarian ethics. The script also examines distributive justice, inequality, and inequity, advocating for the least well-off in society. Finally, it challenges viewers to confront moral responsibility and the concept of moral distance in a global context.

Takeaways

• 📚 Ethics in public health is guided by a framework that categorizes ethical considerations into four buckets: individuals, groups, nation-states, and global civil society.
• 🧩 Bioethics, applicable to individuals, is based on four principles: beneficence, non-maleficence, autonomy, and justice, which are crucial in medical and public health contexts.
• 🌟 Human rights encompass both civil and political rights for individuals and economic, social, and cultural rights for groups, highlighting the importance of rights in health equity.
• 🤔 Deontological ethics, based on absolute rights and wrongs, contrasts with utilitarian ethics, which focuses on maximizing happiness or utility for the greatest number, often used in public health decision-making.
• 🔍 The concept of 'moral responsibility' at a global level prompts reflection on our duty to address historic injustices and their impact on current global health disparities.
• 🌐 'Moral distance' challenges the notion that physical or emotional distance from a situation lessens our moral obligation to act, a concept relevant to global health initiatives.
• 🏛 Distributive justice, a concept by John Rawls, suggests that a just society is one where inequality is arranged to ensure the best possible situation for the least advantaged members of society.
• 🔄 The difference between 'inequality' and 'inequity' is significant, with the former being a neutral term and the latter indicating systematic unfairness that leads to health disparities.
• 🛑 The 'trolley problem' thought experiment illustrates the complexity of ethical decision-making, showing how our moral judgments can change based on the framing of a scenario.
• 🛍️ The example of sacrificing a pair of shoes to save a child's life is used to discuss moral responsibility in the context of global poverty and the need for affluent societies to contribute to global health.
• 🌱 The video emphasizes the importance of understanding and advocating for ethical principles in public health, including the need for nuanced discussions on ethical dilemmas.

Q & A

What are the four buckets of ethical tools mentioned in the framework for public health?

The four buckets of ethical tools mentioned are: considerations for individuals, groups of people, the nation-state, and global civil society.

What does the term 'bioethics' refer to in the context of public health?

Bioethics refers to the set of principles that guide ethical decision-making in medical and public health contexts, including beneficence, non-maleficence, autonomy, and justice.

What are the two types of human rights discussed in the script, and how do they differ?

The two types of human rights are civil and political rights, which apply to individuals, and economic, social, and cultural rights, which apply to groups of people.

What is the difference between deontological ethics and utilitarian ethics?

Deontological ethics, based on Immanuel Kant's philosophy, asserts that there are absolute rights and wrongs, while utilitarian ethics, developed by Jeremy Bentham and John Stuart Mill, focuses on maximizing the overall good or happiness for the most people.

What is the thought experiment introduced by Philippa Foote to illustrate the complexities of ethical decision-making?

Philippa Foote's thought experiment involves a trolley problem, where individuals must decide between diverting a trolley to kill one person or doing nothing and allowing it to kill five people, highlighting the nuances of deontological and utilitarian ethics.

What is the concept of 'distributive justice' in the context of nation-states?

Distributive justice refers to the ethical concept of how resources and benefits should be fairly distributed within a society, taking into account issues of inequality and inequity.

What is the difference between 'inequality' and 'inequity' as discussed in the script?

Inequality refers to an uneven distribution of resources or outcomes across a society, while inequity specifically denotes a systematic unfairness that leads to such inequalities.

What is the 'veil of ignorance' thought experiment by John Rawls, and what does it aim to illustrate?

The 'veil of ignorance' is a thought experiment where individuals imagine deciding on the principles of justice without knowing their own position in society, aiming to illustrate how much inequality in society should be tolerated.

What are the two key concepts to consider when discussing public health ethics at a global level?

The two key concepts are moral responsibility, which involves taking responsibility for historical injustices, and moral distance, which challenges the idea that physical distance should affect our moral obligations.

What is the example given by Peter Singer in his paper 'Famine, Affluence, and Morality' to illustrate the concept of moral distance?

Peter Singer uses the example of choosing between saving a drowning child at the cost of ruining an expensive pair of shoes versus donating the money equivalent to the shoes to save a child's life in a distant country, to illustrate the concept of moral distance.

Outlines

00:00

🔍 Introduction to Public Health Ethics

The video script begins with an introduction to the concept of public health ethics, emphasizing the importance of ethical decision-making in the field. It outlines a framework for addressing ethical issues, categorizing them into four buckets: individuals, groups, nation-states, and global civil society. The speaker promises to delve into each category, starting with a bird's eye view and then explaining specific concepts such as bioethics, human rights, and utilitarian versus deontological ethics. The goal is to provide viewers with a comprehensive understanding of the ethical considerations relevant to public health professionals.

05:01

🌟 Bioethics and Human Rights in Public Health

This paragraph delves into the principles of bioethics, which are crucial in medical and public health contexts. It introduces four key principles: beneficence, non-maleficence, autonomy, and justice. Beneficence and non-maleficence focus on the balance of risks and benefits in medical interventions, with the aim to do good and avoid harm. Autonomy emphasizes the importance of informed consent, allowing individuals to voluntarily participate in treatments or research. Justice addresses the fair distribution of healthcare resources and the ethical implications of research outcomes, particularly in the context of trials conducted in developing countries.

10:02

👥 Human Rights and Group Ethics in Public Health

The script continues by discussing human rights as they pertain to groups of people, distinguishing between civil and political rights, which are individual freedoms, and economic, social, and cultural rights, which apply to groups and populations. It highlights the importance of these rights in achieving public health goals and the ethical considerations involved in ensuring access to essential services like clean water, housing, education, and healthcare. The paragraph also introduces deontological and utilitarian ethics, setting the stage for a deeper exploration of ethical decision-making within groups.

15:04

🤔 Ethical Dilemmas: Deontological vs. Utilitarian Ethics

This section explores the philosophical underpinnings of ethical decision-making, contrasting deontological ethics, which are based on absolute rights and wrongs, with utilitarian ethics, which prioritize the greatest good for the greatest number. The speaker uses the famous trolley problem to illustrate the complexities of these ethical frameworks, showing how the way a problem is presented can influence our moral judgments. The discussion encourages viewers to reflect on the nuances of ethical reasoning and the importance of considering different perspectives.

20:05

🏛 Distributive Justice and Inequality in Nation-States

The focus shifts to the ethical responsibilities of nation-states, particularly in the realm of distributive justice. The paragraph clarifies the difference between inequality, which is the uneven distribution of resources, and inequity, which results from systematic unfairness. It challenges the viewer to consider the appropriate level of inequality in society, referencing John Rawls' theory of justice and the concept of the 'veil of ignorance' to explore the idea of a just society where the least well-off are as well-off as possible.

25:05

🌐 Global Public Health Ethics: Moral Responsibility and Distance

The final paragraph broadens the ethical discussion to a global scale, introducing the concepts of moral responsibility and moral distance. It prompts reflection on our obligations to address historical injustices and the ethical implications of our actions in a global context. The script references Peter Singer's thought experiment about the moral obligation to help those in need, regardless of geographical distance, and challenges the notion of moral distance as a barrier to fulfilling our ethical duties.

Keywords

💡Ethics

Ethics refers to the moral principles that govern a person's or group's behavior. In the context of the video, ethics is the philosophical basis for determining right and wrong in decision-making and actions, especially in public health. The script discusses various ethical frameworks and principles, such as bioethics and human rights, that are crucial for navigating complex public health issues.

💡Bioethics

Bioethics is the study of ethical issues arising in the fields of medicine and biology. The script outlines four key principles of bioethics: beneficence, non-maleficence, autonomy, and justice. These principles guide medical professionals and researchers in making ethical decisions that prioritize patient welfare and fairness in healthcare delivery.

💡Beneficence

Beneficence is the ethical principle that promotes actions that are in the best interest of the individual, aiming to bring about benefits and prevent harm. The script uses beneficence to discuss the obligation of medical professionals to ensure that patients benefit from their treatments and are not subjected to unnecessary risks.

💡Non-maleficence

Non-maleficence is the ethical duty to 'do no harm.' It complements beneficence by emphasizing the avoidance of harm alongside the pursuit of good. The script mentions non-maleficence in the context of medical interventions, where professionals must balance potential benefits against possible harm.

💡Autonomy

Autonomy in ethics refers to the capacity and right of individuals to make informed decisions for themselves. The script discusses autonomy as a critical principle in bioethics, highlighting the importance of patient consent and the ability of individuals to choose their medical treatments freely.

💡Justice

Justice in the context of bioethics involves the fair distribution of healthcare resources and ensuring equal access to medical services. The script touches on justice in relation to clinical trials and the ethical obligation to distribute benefits and burdens equitably among participants and society.

💡Human Rights

Human rights are the fundamental rights to which every individual is entitled. The script distinguishes between civil and political rights, which apply to individuals, and economic, social, and cultural rights, which apply to groups of people. These rights are essential in public health, as they influence policies and actions that affect health outcomes.

💡Deontological Ethics

Deontological ethics, rooted in the philosophy of Immanuel Kant, is the approach that certain rights and duties are absolute and should be followed regardless of outcomes. The script uses deontological ethics to explore the concept of inherent moral wrongs, such as the prohibition against killing, even in complex scenarios.

💡Utilitarian Ethics

Utilitarian ethics, associated with Jeremy Bentham and John Stuart Mill, focuses on maximizing overall happiness or utility. The script contrasts this with deontological ethics, using thought experiments to illustrate the challenges of deciding what is ethically right based on outcomes versus adherence to moral rules.

💡Distributive Justice

Distributive justice is a principle of fairness in the distribution of resources within a society. The script references John Rawls' theory of justice, which posits that a just society is one where inequality is allowed only to the extent that it improves the situation of the least advantaged members of society.

💡Moral Responsibility

Moral responsibility refers to the obligation to take responsibility for one's actions, especially in the context of historical injustices. The script prompts viewers to consider the extent to which individuals and societies should be held accountable for past wrongs and their present-day implications.

💡Moral Distance

Moral distance is the concept that the physical or emotional distance from a moral dilemma should not affect one's sense of responsibility. The script uses Peter Singer's thought experiment to challenge the notion that we can ignore the suffering of distant others simply because we are not directly confronted with it.

Highlights

Ethics is a framework for decision-making in public health, categorized into four buckets: individuals, groups, nation-states, and global civil society.

Bioethics includes four principles: beneficence, non-maleficence, autonomy, and justice, which are crucial for medical and public health professionals.

Human rights encompass both civil and political rights for individuals, and economic, social, and cultural rights for groups, affecting public health policies.

Deontological ethics, based on Immanuel Kant's philosophy, asserts absolute rights and wrongs, in contrast to utilitarian ethics which focuses on outcomes.

Utilitarian ethics, developed by Jeremy Bentham and John Stuart Mill, emphasizes maximizing happiness or utility for the greatest number of people.

The trolley problem illustrates the complexity of ethical decisions, showing how framing affects moral judgments in deontological vs. utilitarian terms.

Inequality is the uneven distribution of resources, whereas inequity is systematic unfairness leading to such disparities, with different implications for public health.

Distributive justice, as discussed by John Rawls, involves tolerating inequality only to the extent that it benefits the least advantaged in society.

Global public health ethics considers moral responsibility for historical injustices and the concept of moral distance in assisting those in need worldwide.

Peter Singer's thought experiment challenges the notion of moral distance, arguing that our responsibility to help should not be diminished by physical distance.

Ethical considerations in public health require a nuanced understanding of individual rights, group dynamics, national policies, and global responsibilities.

The importance of advocating for good policies based on a deep understanding of distributive justice and equity for public health professionals.

The necessity for public health professionals to balance immediate enforceability of rights with long-term aspirational goals for groups.

The ethical dilemma of autonomy in medical interventions, where patient consent is paramount unless capacity is compromised.

The role of ethical considerations in the aftermath of clinical trials, ensuring participants receive fair benefits from research outcomes.

The philosophical debate between deontological and utilitarian ethics is crucial for making decisions regarding groups in public health.

The significance of understanding both inequality and inequity to effectively address health disparities from a public health perspective.

Transcripts

today we're talking about public health

ethics

ethics is the philosophy around how it

is that we should live what is right in

terms of the decisions and actions that

we take there are a lot of tools that

can be used to think through ethical

issues and ethical problems i put those

tools into four buckets right and this

is a framework that i've developed that

i found quite useful in my career in

public health to think through ethical

problems right so we've got to think

through ethical problems with respect to

individuals groups of people the nation

state and the responsibilities of the

nation state and of course global civil

society okay i hope you find this useful

okay so this is the overall framework

this is the in a nutshell this is the

bird's eye view in this framework you

can see a couple of words and ideas that

you might not be familiar with don't

worry don't panic we're going to go into

each of these things individually one at

a time and i'm going to explain each of

them quite carefully to you just so that

we can just quickly go through the the

overall

idea with respect to individuals we're

going to talk about bioethics i'm going

to explain what is meant by bioethics

and the principles around bioethics

we're going to talk about human rights

now human rights

applies both to the individual

but also to groups of people and they're

applying different ways right so there

are human rights called civil and

political rights and they apply to

individuals and there are human rights

called economic social and cultural

rights and they apply to groups of

people so that's why that the idea of

human rights spans both of these buckets

right in the groups of people buckets

we've got this idea of deontological and

utilitarian ethics right and that's a

really really interesting conversation

about what is right in terms of deciding

what to do with groups of people

extremely important in the context of

public health so we really want to pay

attention and focus on that part of the

conversation then with respect to

countries we want to understand how it

is that nation states and governments in

nation states should make decisions

about the people within the nation

states especially this idea of

distributive justice who has what how

much inequality and inequity is

permissible in the context of a country

right and we're going to distinguish

between the idea of inequality and

inequity so these are ideas and we're

going to tease that out during the talk

and that's super interesting and i know

a lot of you might think well i'm not

part of the government so why does that

matter to me as public health

professionals we need to advocate for

good policies so understanding the

arguments that underpin distributive

justice extremely important for public

health professionals

and then finally we all form part of a

global community global civil society

and there are some ideas and they fall

under two ideas that i've kind of got to

understand and enjoy thinking about one

is moral responsibility and that other

is moral distance so we're going to talk

about all of these things one at a time

thanks for watching until now stick with

me if you're feeling a bit confused

don't worry everything will be clear

very soon okay so hang in there

[Music]

when we think about what is right and

what is wrong with respect to

individuals right we've got this idea of

bioethics and bioethics is something

that applies obviously in the medical

profession more broadly it's not just a

public health issue but of course it

does apply in public health it's also

something that's used in medical

research and by biomedical research a

lot okay in terms of clinical trials et

cetera et cetera so what do we mean when

we talk about bioethics firstly we're

talking about these four principles that

we've all agreed to in the medical world

that we think these are what we think

are important some people add to this

this list isn't a definitive list but

these are the four most commonly ones

that are talked about

right these are terms you may not have

heard before beneficence non-mulphy

non-malfeasance autonomy and justice

beneficence is really the idea that we

should be in the first instance doing

what we think is in the best interest of

the person in front of us right so they

should benefit from whatever it is that

they're participating in and the

non-malfeasance is almost the other side

of the same coin we should not be doing

something or taking an action that we

believe or we know we even expect to not

be in that person's interest to do them

harm now where this is a little bit

tricky is of course with any medical

intervention there are always inherently

a certain risks that we need to take

into account

but when we think about the balance of

the risks and benefits we should draw

the conclusion that we think that this

person will benefit from it and we do

not believe that it's likely that they

will be harmed by our action

notwithstanding the fact that of course

things can go awry and with any medical

or public health intervention there is

always an element of risk

which brings us really to the next at

the next bullet point here which is

autonomy the person needs to be able to

engage with whatever treatment with it

whatever intervention that we're

applying

of their own volition right they need to

have the capacity to make a decision and

they need to have the autonomy to say

yes or no to that particular

intervention and if they don't want to

participate they should be given the

freedom not to now there are exceptions

to that there are times when people

don't have what we call capacity right

there might be severe mental illness or

neurological decline in which a person

isn't able to take a decision on their

own behalf and under those circumstances

their capacity to make a decision is

something that is clinically evaluated

there are very definitive criteria that

get get applied in those circumstances

and making a decision on behalf of

someone isn't taken lightly it's it's a

very serious thing and there are ways of

doing that but that you know but for the

most part for most people we want to

make sure that they have autonomy and

they can decide or decide to or not to

participate in whatever it is that we're

wanting to apply okay stop the video

we're going to go back to talking about

ethics in just one minute i just want to

quickly say a big thank you to the

university of limerick for providing

support to create this video

one of the things that i absolutely love

about the university of limerick's

public health program is that there's an

emphasis on making sure that they are

preparing you for the workplace in other

words they are not just teaching you the

theory of course you're learning all of

the public health theory but they're

teaching you that theory in the context

of making sure that you are following

your graduation really able to make a

real contribution in the public health

space

so if you're thinking of studying public

health take a look at the university of

limerick highly recommend it i think

you'll love it okay let's carry on

talking about public health ethics

and the final thing is justice we want

to make sure that there's no unfairness

that's being applied in other words the

treatment that we're applying isn't

somehow being applied people aren't

being given access to it as a function

of their gender or the ethnicity or the

or some other reason we want to believe

that there's an element of justice we

also want to believe that where people

have for example participated in a trial

that they also benefit from the from the

outcomes of the research of that trial

okay and that's actually something

that's become extremely important with

respect to hiv trials that we've done in

africa where there were people whom

if following the trial the treatment

that they had

spent their risk themselves in a lot of

ways to prove worked was not made

available to them that would have been

considered to be a big injustice in

actual fact with respect to hiv trials

in africa with antiretroviral drugs for

the most part those people were given

antiretrovirals for life even subsequent

to the ending of the trial which i think

was a real boon and demonstrated a real

understanding of this notion of justice

okay so that's bioethics i'm not going

to carry on about that because really

there's so much more we need to talk

about the next thing we're going to talk

about is human rights now there's two

types of human rights have alluded to

that fact

and when we're talking about the

individual we really want to talk about

what's called civil and political human

rights and these are rights that are

applied to individuals these are like

their freedom to vote freedom to

assemble the right to be free from being

tortured

these are things that as an individual i

can request that that right be protected

right i can ask that right be enforced

and i can ask for it to be enforced now

i can today ask that i not be tortured i

can today ask that i have the right to

be able to vote and the reason i'm

making a big deal about the immediacy of

the enforcement of that right is because

it stands in juxtaposition to the other

kind of right we're going to talk about

just now which can't be enforced in any

immediacy right so civil and political

rights these are individual freedoms and

of course we believe that they're

enforceable they should be enforceable

they aren't always enforced we agree as

a global civil society that these are

important and that they should be

enforced and we bestow this right on one

another in other words we agree

collectively to protect

each other's rights to access these

freedoms and of course all of this has

implications for health right if i'm

tortured that's

that's bad for my health if i don't have

the right to participate in civil

society and vote and assemble i don't

have any agency then to have decisions

about how society is managed that might

affect my health i can't influence that

i can't advocate for my own health

environment so these all have

implications for health okay

we're going to now talk about groups of

people and i'm going to start off that

conversation just by continuing to talk

about human rights and the aspect of

human rights that pertains to groups of

people and then we're going to get into

the deontological and utilitarian ethics

which is super duper interesting so

stick with me for that

when we're talking about public health

effects for groups of people again we

want to talk about human rights but this

time we're talking about economic social

and cultural rights right for

individuals it was civil and political

rights those were the freedoms of

individuals these are rights of groups

and of populations

now these are rights like the right to

access clean water the right to housing

the right to education the right to the

highest attainable standard of health

notice that it's not the right to health

but it's the right to the highest

attainable standard of health and that

there's an important difference there

now obviously these things cannot be

enforced remember we said the civil and

political human rights are things that

you could enforce now in the immediate

effect you could have those rights

respected those freedoms could be

attained things like access to fresh

water education housing the right to the

highest attainable standard of health

these are things that that take time to

be put in place they're aspirational

they're normative these are things that

we work toward that we need to invest in

and we and we kind of wanted to get to

right so they can't be enforced in the

immediate effect but there are things

that we believe that people should have

or at least most places around the world

most countries and most governments

believe in these economic social and

cultural rights so they're very

important they're aspirational they're

four groups they have certainly have

public health implications next we're

going to talk about deontological

utilitarian ethics this is maybe the

most important concept that you to get

your head around and i'm going to

just create a new board to talk about

them because there's some interesting

thought experiments that you can use to

to really better understand

the nuances of deontological and

utilitarian ethics

okay deontological and utilitarian

ethics these are two important concepts

and you're really going to enjoy this

it's super interesting right

genetological ethics were developed by

immanuel kant and essentially the idea

there was that there are absolute rights

and wrongs there are things that are

wrong things that are wrong things that

are wrong

simply because we know that inherently

morally ethically these things are wrong

and they're wrong by definition right so

you might say to kill a person is wrong

no matter what the circumstances

it's always wrong to kill a human being

utilitarian ethics developed by jeremy

bentham and and john strutmills

said actually no

what matters is the outcome of your

actions you really want to do the thing

that translates into the most good for

the most people or you know sometimes it

was framed as the most happiness for the

most people but really you're trying to

maximize the utility of humanity or of

group of people and that's what defines

what is right and what is wrong now

interestingly when people are confronted

with these two ideas for the most part

most people

immediately put themselves into one or

other bucket most people sort of have a

knee-jerk reaction and feel as if they

uh resonate with either uh jeremy

bentham or immanuel kant and they they

find themselves in one or other camp

along came somebody by the name of

philippa foote

and she said look it's not quite that

straightforward and she developed a

thought experiment

to try and highlight how difficult it is

to really distinguish right and wrong

with respect to these two different

frameworks and the thought experiment

went along the lines along i want you to

do this with me use your imagination and

do this thought experiment and you'll

see exactly what i mean

right so she said look imagine a tram or

trolley and in this case you'll see i've

drawn a little train it's not a very

good drawing but you know it's the best

i could do and it's going along a track

and

it's heading

on the track it's natural courses to go

down this way and some evil villain has

tied

five people to the track

and if it goes down that track the train

or the tram or the trolley is going to

kill all five people for sure they they

will not survive

interestingly you're standing a little

ways off you're in the little hut that

the

train people stand in and you've got a

lever that you can pull and if you pull

that lever the train will be diverted

onto an alternative track and on this

alternative track of course uh what's

going to happen is there's just one

person tied to the alternative track and

that person will get hit by the train

and they'll die but you'll have saved

the five people and so the first

question that philippa foot asked is

would you pull the lever

and save the five people

knowing of course that there'd be one

person that still did die when asked and

you might find this yourself as you

listen to me

most people respond they would pull the

lever and make that decision

now interestingly that is a utilitarian

decision right it's maximizing the

utility of this particular set of

circumstances it is killing a person so

it's doing something that would would

consider to be deontologically wrong

but it is we're maximizing utility but

then she said let's take this experiment

a step further

and let's imagine that you now don't

have a lever but instead you've got a

footbridge

and i would try and draw the footbridge

for you but i really you know the train

is the best i could do in terms of

drawing i wouldn't get this right but

you've got a foot bridge that's going

over the track

you do not have a lever to pull but

you've got a footbridge and on that

footbridge

there's a

and you could push the off the

footbridge onto the track and that

footbridge that tram would would you

would push him he would fall off

and he'd land on the track and die

and he'd be hit by the train but he

would stop the train

and of course the the five people would

be saved

so the question is would you

climb onto that footbridge and kill the

push him off the edge and

when the problem is framed like that

most people overwhelmingly

the vast majority of people said they

wouldn't do that they couldn't do that

now strictly speaking those two

scenarios are from an ethics and moral

point of view the exact same thing right

you're sacrificing one person to save

five

but the problem is it's framed in a

different way and our brain processes

that information in different ways when

you're pulling the lever the part of

your brain

that

considers the ethical dilemma simply

makes a calculation it's a sort of

prefrontal cortex it just sort of says

five is more than one that's the better

option let's save the five when you're

thinking and imagining yourself on a

footbridge

actually getting up close and personal

and killing a person suddenly your

emotional centers are evoked and you

make that ethical decision in a

different part of your brain and under

both circumstances you are quite sure

that you're making the right decision

and most people will swap and then of

course the trolley experiments can get

changed in multiple ways

you could say well on the footbridge the

person that you're going to push off the

footbridge and they're going to die

to save the five isn't a but

rather it's the evil villain that tied

the five people there in the first place

and then suddenly people are like oh

hang on hold the phone we don't mind

killing him or her

let's you know that's fine that's

justifiable so there are multiple

versions and iterations there's versions

of the trolley experiment where the

track loops back on itself and it gets

more and more complicated but the point

is every iteration of this thought

experiment demonstrates to us

that what we think is right and wrong is

for the most part a function of how it

is that the problem is framed and we

need to think about that we need to keep

that in mind very carefully when we get

into debates with people about moral and

ethical public health problems and not

fall into the trap of simply believing a

particular paradigm because it's framed

in a way or is just sort of too sort of

too much on the side of a pure

calculation it doesn't take the humanity

of the situation into account we have to

be more nuanced than that now

what does this mean

have i taken away two two tools from you

or have i given you two tools that you

can use i don't know uh all i know is we

can't go into these conversations

without having that introspective nuance

that ability to kind of really reflect

on our own position critically and make

sure that when we go into an argument

about ethics that we're aware that

there's often another side to the story

which may be quite compelling depending

on how it is that that story is being

read

okay so we've talked about the

individual level we've talked about

groups of people now we're going to talk

about the nation-state countries how it

is that countries and governments should

apply the ideas of ethics public health

ethics and decisions they make

specifically with respect to this idea

of distributive justice and inequity and

inequality

okay before we start talking about

distributive justice

and there's a fantastic paper i'm going

to talk about by john rolls i want to

talk about the idea of inequality and

inequity these two terms get banded

about they sometimes get used

interchangeably they mean different

things and it's really important that we

understand them if we're going to really

talk about the concept of justice and

distributive justice okay so let's just

talk firstly about inequality

inequality is when there's an uneven

distribution of something across social

delineations right it could be any

delineation it could be gender it could

be short people tall people uh irish

people south africans any delineation

any way of dividing society up when

there's an uneven distribution of

something across those delineations we

call it inequality right now not all

inequality is bad so men

are taller than women that's not

necessarily a bad thing it's just a

thing just it happens it's just a fact

of the matter uh dutch people are taller

than british people

again it's not a good thing it's not a

bad thing it's just a thing and we just

we just live with it there are some

inequalities however

that exist because of pre-existing

unfairness

systematic unfairness in society and we

call that unfairness inequity so

inequity is a systematic unfairness that

leads to

inequality good example is apartheid

south africa had rules and legislation

in place

that meant that black south africans had

economic disadvantages and health

disadvantages and whole and educational

disadvantages i mean a whole string of

freedoms denied to them there was a

systematic unfairness in society and

that led to inequalities so there was

inequity that led to inequalities now

importantly when we're talking about

health

there is a tendency to use this term

health inequities which are

health inequalities that are a function

of an unfairness and and that's a real

thing there are

unfairnesses that lead to you know there

could be economic unfairnesses there

could be all sorts of unfairnesses in

south africa that have health

consequences

and there's this term

there's this catch-all term called

health inequity that people try to use

to capture those things the trap that

people fall into is believing that those

are and only those are the inequalities

that we should be addressing and that's

not true

while it is the case that health

inequities these inequalities that are a

function of some sort of unfairness have

to be addressed at a social level we

need to kind of make sure that we live

in a fair society

that doesn't translate into these sorts

of inequalities it's also true that

health inequalities

that have nothing to do with unfairness

if it is possible for us to address them

we should

okay let me give you an example as a

caucasian i'm more likely to develop

skin cancer than somebody that's darkly

pigmented

right that's not an unfairness i'm not

being cheated by the world

it's just a difference a biological

difference between myself and my

counterparts that are darker than me

should we try and address that as a

public health community of course we

should be telling people like me to wear

sunscreen to stay out of the sun

and you know to avoid some of the the

risks associated with skin cancer all

right so it's not just an inequalities

that are a function of unfairness that

need to be addressed we need to address

any health inequality where we are able

to and of course it's true that where

there's inequity where there's

unfairness absolutely we have to address

that that's you know that almost goes

without saying but

it's also true that it has to be said

because we see examples of it all over

the world where unfairnesses are not

being addressed okay so that's

that's inequality and inequity and

that's important to understand that

because next we're going to talk about

this idea of distributive justice and

how much inequality in a society should

we tolerate

okay when we talk about distributive

justice there was a paper written by

somebody by the name of jonathan rawls

and

he wrote this paper called theory of

justice and it was a very influential

paper and it talked about the idea of

inequality in society and how much

inequality we should tolerate

and these are very badly drawn scales

down here and i'm going to get back to

those in a second but really john rolls

came up with a thought experiment and

again i want you to do this thought

experiment in your mind as as i talk it

through imagine yourself in the

situation john said okay put yourself

behind what he calls the veil of

ignorance he calls it the original

position

it's you remove yourself from your life

imagine that you're behind this veil of

ignorance and it's called available

ignorance because on that you don't know

what your life was like on the other

side you've been removed from life

and the world

and you don't remember whether you were

black or white whether you were

tall short male female a south african

or irish you don't know anything about

the life that you're going to go back to

and you're going to go back to that life

now

given that you're going to go back to

that life

and you don't know who you're going to

be

what level of inequality

would you opt for

while you're here on on this side of the

veil of ignorance what would you

consider to be appropriate

knowing that in that the world you're

going back to could be

dramatically unfair with huge

inequalities and you could be at the

bottom end in fact in the world that

we're living at the moment it would be

overwhelmingly likely that you would be

somewhere in the sort of bottom end you

know the sharp end of inequality you

know and we do live in a world where a

very very few people you know kind of

really control the vast majority of the

wealth in the world so the question is

from behind the veil of ignorance where

would you how much inequality would you

want in society when you came back it's

an interesting question and he came up

with a way of thinking about it a way to

kind of answer that question because

it's you know on the one hand you might

say oh no i want to come back to a

completely you get an egalitarian world

where

there's no inequality whatsoever and he

argued against that as well by the way

and this is where our three little

scales come in and here's here's what

john rolls kind of suggested he said

each of these scales represents sort of

a certain level of inequality in society

and he was saying look you could have a

completely egalitarian society with it

everybody has exactly the same amount of

absolutely everything and you don't

really have any

any people that are tremendously poor

the other extreme you could have a

situation where you have a lot of

inequality but it might translate into a

tremendously wealthy society but they

would in that society be some people who

are tremendously poor

now john rolls kind of argued that what

you you don't really want that either

and although to a large extent that is

the world that we're currently living in

he argued that what you really want is a

world where there's

some inequality

but only inequality in so much as it

translates into the least well of

being as well off as possible in other

words in this scenario because of a

little bit of inequality and sometimes a

little bit of inequality could spur

competition and incentives et cetera et

cetera i mean there are reasons why some

inequality in the world actually has

economic benefit but he said you only

want to tolerate as much inequality as

translates into the least well-off so

the people at sort of this side of

the equation being as well off as

possible in other words

where these people over here

are better off than these people over

here

so if we were to draw a line a dotted

line of their level of well-being it's

assumed that they're over here where the

least well-off in society are the best

that they could possibly be

that's the level of inequality that we

should aspire towards more inequality

could lead to the least well of being

less well-off than

this completely egalitarian situation

even if society under those

circumstances was a richer society so he

was saying let's not go for that let's

go for a sort of middle ground with the

least well of uh in other words he said

the benchmark for what we should

tolerate and what we should aspire

toward is how well off or how are

the least well-off in society that's our

barometer those are the people that we

need to be concerned about

not the overall economy not the wealth

of the nation not the gdp per capita not

the economic growth rate or none of that

how well off are the least well-off in

your society that's the measure

of whether or not that's the level of

inequality that you should tolerate and

that's in terms of distributive justice

what it is that you should be aspiring

towards okay i hope that was useful now

we're going to go on to thinking about

public health ethics from a global

perspective

okay so we've talked about the

individual we've talked about groups of

people we've talked about countries and

so obviously the next thing to talk

about is at a global level let's talk

about moral responsibility and moral

distance

when we talk about public health ethics

at a global level there's two ideas that

we need to think about one is moral

responsibility and the other is moral

distance now i don't have the answers to

some of the questions that these ideas

pose but i do think that we need to be

cognizant of them moral responsibility

is the extent to which we need to take

responsibility for historic injustices

that we have benefited from

okay and there's lots of examples of

that and the question that needs to be

grappled with would be how far back do

you go and to what extent do you

take moral responsibility for historic

injustices and what does that mean how

should you respond to that so there's

this historic injustice you're going

back in time you take moral

responsibility for things that happened

in the past the other is physical

distance and this is this idea of moral

distance

now peter singer wrote a very

influential paper called famine

affluence and morality

and in it he posed a thought experiment

and he said look if you're walking down

the road

and you pass a child drowning in the mud

and you're able to save that child

you're just well able to save that child

the problem is that if you were to save

that child the only way you could do it

would be to get your feet stuck in into

the mud and there you've just bought a

very expensive pair of shoes

and those shoes would be ruined

i think most of us agree that you

shouldn't care too much about the shoes

but you should sacrifice the shoes and

help the child out of the mud and save

the child's life and that's my little

diagram here by the way that's a shoe

stuck in the mud i know it doesn't look

like it i'm not a great artist as you've

probably figured out by now

now so we all agree save the child

sacrifice the shoes none of us have a

problem with that

but something that peter singer pointed

out is that in actual fact we are faced

with that exact dilemma all of the time

right there are reputable charities out

there

to which we could give

the equivalent of

an expensive pair of shoes in full

confidence that that might translate

into a child's life being saved or

perhaps a child being educated or

treatment for a child uh to be you know

to be treated for some sort of illness

but

these these are children in africa or in

southeast asia and some part of the

world where they're

so far away from us that it's easy for

us to detach ourselves emotionally from

their plight

and we absolve ourselves of this sense

of moral responsibility so peter singer

was saying basically the distance

shouldn't matter

distance isn't an issue there's no such

thing as moral distance essentially the

responsibility to save a child's life if

you're able to

should apply

regardless of where it is in the world

that you are so interesting idea

interesting challenge to us all i hope

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thanks for watching hope you enjoyed

this take

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