Where are the boundaries for ethical population health policy?

By Alison Hall

18 January 2013


At the start of a new year, there has been an explosion of new policy initiatives. King’s Fund’s Richard Humphries noted in his blog on 3 January the increasing divergence of policies relating to health and social care – a distinction driven by austerity, demographic change and differences in the way that the social care and health systems were set up in the 1940s. He suggests that a key question for 2013 is how the NHS should be funded in the light of these increasing constraints.

At the same time, other policy think tanks are responding with ‘innovative’ ideas for health improvement on a population basis. One example is the proposal from the Local Government information Unit that exercise classes should be prescribed by GPs; that attendance should be monitored using smart technology, and non-attenders sanctioned by adjustments to their benefit or welfare payments.

Whilst it is certainly true that individuals can improve their own health through concerted effort, the relative merits of ‘carrots’ or ‘sticks’ to motivate sustained behaviour change remain less clear. A significant concern, especially where there is an uneven balance of power, is the extent to which these developments constitute undue influence or even coercion. These questions are highly pertinent in relation to public health, which, in a 1988 Report, Sir Donald Acheson coined as "the science and art of preventing disease, prolonging life, and promoting health through the organised efforts of society".

For those, like the PHG Foundation, who are interested in how genomics may be harnessed to improve public and population health, these proposals raise an interesting series of issues. At the centre of this debate is a question about how far it is legitimate for public authorities to use sanctions linked to one statutory function to maximise outcomes in another; in this case, maximising population health. 

To take another scenario:

  1. Public health has recently become a local authority function in England and Wales;
  2. Recent scientific research has shown the promise of genotyping populations to identify common genetic variants that cause common cancers including breast and prostate cancers;
  3. Other research suggests that for some drugs, having a certain genotype makes it more likely that the drug will be less effective or cause known side effects.

Does it follow that local authorities should target preventative screening and treatment to those that genotyping indicates will be most likely to benefit? Or that drugs delivered within a social care environment should be withheld from those most likely to be harmed or suffer adverse risks? And - applying the same logic - that those who refuse genotyping should take responsibility for any adverse consequences that result (such as bearing the cost of a screening intervention, or cost of ongoing treatment for adverse events from prescribed medicines administered within social care settings?).

As increasing austerity seems inevitable, coupled with growing demands for accountability, the manner in which society ‘organises’ itself to achieve shared goals is profoundly important, and perhaps exemplifies why policy research clarifying the ethical, legal, social and organisational impact of proposed policy development continues to be necessary in today’s world.

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