Translational ethics: making tools
Borchers, a philosopher researching decision-making and the role of ethical tools therein, pronounces that ethical tools have to be developed together by academics and decision-makers (Borchers 2016). We agree that bridges have to be built between the academic ethical and practical health discourse to work together on ethical normative guidance and also ethical tools. This way it can be best assured that ethical concepts are well used and understood in terms of what they could mean in practice. Ethicists and decision-makers in environment and health have to understand each other. On the one hand, ethicists have to understand what the technical and empirical problem is when making difficult and ethically relevant choices in environment and health. On the other hand, decision-makers have to understand what ethical concepts mean: what their scope is, what they imply, how to develop arguments and judgements involving moral norms and values.
For this reason, we would like to emphasise that translational aspects between these two paradigms - philosophical ethics and environment and health - need to take place and need to be facilitated. Only in an interdisciplinary discourse, which we would like to call translational ethics (Van Duin et al. 2015), with members of both paradigms, would the development of a meaningful tool be successful. Not only can philosophers develop ethical tools for environment and health, or the other way around, environment and health scientists and decisionmakers can also develop ethical tools for their paradigm.
Proposal for an ethical toolbox for environment and health
Having said that, ethical tool development needs an interdisciplinary approach, we would like to make a first proposal for a tool. However, such a proposed tool still needs further development and validation in wider interdisciplinary discourses and trial phases in practice.
Our proposed ethical tool for environment and health is a list of ethical norms in forms of ethical principles (see Table 10.1) that can be broken down to normative questions that then, again, can be used like a checklist, or, as we prefer to call it, an “aide memoire” that can be a starting point for ethical analysis and reflection (Schröder-Bäck et al. 2014). The first seven principles are as presented also in Schröder-Bäck et al. (Schröder-Bäck et al. 2014). Additional principles are “pru-dence/precaution” and “honesty” from Malone and Zölzer (Malone and Zölzer 2016), who reflected on and suggested norms and values for environment and health. Additional to this, an ethical tool of principles in the format of an “aide memoire” is a suggestion of how to apply these principles.
An “aide memoire” of principles and normative questions
as an ethical tool
The following principles are guiding norms when exploring the moral dimensions of an environment and health challenge. The principles are presented systematically and not in a certain hierarchical order. Indeed, there is no predefined weight to each of the principles. What role they play in making arguments and judgements is to be determined in the process of ethical justification and depends on the context and specificities of the situation. Here, in the formulation of the questions that are listed below in this “aide memoire,” the ethical principles are specified as normative questions, directing the attention to concrete potential moral pitfalls of environment and health. In the specification we speak of an
Table 10.1 Ethical principles for environment and health as basis for the “aide memoire” tool
Respect for autonomy Justice
Health maximisation Efficiency Proportionality Prudence/precaution Honesty
Ethical tools for decision-makers 161 “intervention” (rather than a policy or any other term). “Intervention” is to be understood as a placeholder for a planned action or inaction in the context of environment and health. For example, the iodine tablets distribution programme in Aachen, or the development of a guideline on evacuation in case of a nuclear power plant accident.
Beneficence and non-maleficence
The first principles to be mentioned are “beneficence” (do good) and “non-maleficence” (do no harm). They both reflect the longstanding health ethics tradition that is founded in the Hippocratic ethos that health professionals shall do good to their individual patient or client and shall avoid doing harm. Thus, the specified questions relating to these principles in the context of environ-ment and health are:
- • Is the environment and health intervention promoting the health of and doing good for all persons affected by this intervention?
- • Will no avoidable harm be done to individuals by the proposed intervention?
Respect for autonomy
The bioethicists Tom Beauchamp and James Childress (2001) recognised that this Hippocratian normative perspective is not sufficient for the context of modern biomedicine and added two further principles. First, there is “respect for autonomy:” Given that relevant normative dimensions of health are not only “good” and “harm,” and, even more, it is difficult to say what good and harm is in the health and environment context, the will of individuals has to play a role. Beauchamp and Childress illustrate this with the example of aggressive therapies, which might add to the life expectancy, but do not lead to gains in quality of life. Here, they argue, the norm that the will and decision-making capacity of patients and citizens are to be taken into account as well is very relevant. Indeed, the will of the patient can overrule the other two principles that demand the health professional to do good and avoid harm. From this norm to respect the will and decision-making capacity of patients and citizens, the following questions could lead the environment and health professional to consider:
- • Is the environment and health intervention refraining from coercion and manipulation, but rather supporting the choice of citizens?
- • Are citizens well informed about the intervention?
- • Is “informed consent” to take part in the intervention considered?
- • Does the intervention raise the ability to exercise autonomy?
- • Is self-responsibility not only demanded, but possible for every person?
- • Are privacy and personal data respected?
- • Is the self-respect of individuals or of populations supported and respected?
- • If the intervention is paternalistic, is this justifiable?
As Beauchamp and Childress convincingly argued, the other principle that has to be added to the Hippocratic ethos to reflect a relevant ethical normative scope is the principle of justice. Justice asks if the benefits and burdens of an intervention are distributed in a fair way. It furthermore asks if (sub-)populations, and especially vulnerable populations, are not treated unfairly (e.g. are stigmatised or discriminated against). For the context of environment and health, specific questions of environmental justice could be specified:
- • Is the proposed intervention not putting sub-populations at risk of being excluded from public goods and benefits?
- • Is no one stigmatised, discriminated against, or excluded as a consequence of the proposed environment and health intervention?
- • Does the intervention not enlarge social and health inequities, but rather works against inequities?
- • Does the intervention consider and support vulnerable sub-populations?
- • Does the intervention rather promote than endanger fair (and real) equality of opportunity and participation in social action?
- • Does the intervention refrain from eroding senses of social cohesion and solidarity?
- • Are aspects of procedural justice - such as transparency, participation -respected? Are all stakeholders heard and no (critical) stakeholders excluded on purpose?
These four principles of bioethics, as mentioned earlier - and their context sensitive specifications in form of questions - are relevant for environment and health as well (Zôlzer 2015). However, we believe that more principles should be included in an environment and health “aide mémoire.” There is the principle of “health maximisation” that carries the normative aspect that good has to be done to a population, as the principle of “beneficence” did for the individual level. Health shall be maximised, and then be also fairly distributed at the same time, which already shows the necessary normative intertwining of the norms of health maximisation and justice. From the principle of “health maximisation,” one could derive ethical questions such as:
- • Is the environment and health intervention indeed suitable for improving population health (health in a wider sense, including the avoidance of fear, panic etc.)?
- • Is the intervention evidence-based and effective (and more so than alternatives)?
- • Does it have a positive sustainable, long-term effect on the public’s health?
When speaking of “maximisation” and “effectiveness,” we can and should also emphasise the moral dimension of “efficiency.” In the context of public and environment and health, resources are scarce, and thus one has to also consider opportunity costs of actions. Choosing one intervention might also mean to choose it over another intervention, or that resources are not available for other interventions that also have the potential to do good or work against health ineq-uities. As such, efficiency is also a moral norm that is of relevance, and it could be broken down into questions such as:
- • Is the proposed environment and health intervention cost-effective?
- • Is the intervention more efficient than alternative interventions?
Another principle that has also been proposed for other public health ethical contexts is “proportionality.” Learning from interventions in the past (which took the “sledgehammer to crack a nut” and thereby infringed on aspects of autonomy), we would like to formulate the following question:
• Is the environment and health intervention the least infringing of all possible alternatives?
Malone and Zolzer (2016) added “prudence/ precaution” and “honesty” as meaningful normative additions to an environment and health ethical framework (in the context of radiation protection in diagnostic radiology). “Prudence,” which they seem to use identically to “precaution,” to them means that “where an action potentially causes a serious irreversible harm, measures to protect against it must be taken even if the causal relationships involved are not fully established scientifically” (Malone and Zolzer 2016: 3). A question for the “aide memoire” that could be inferred from this principle is:
• Are sufficient measures being taken to protect against potential - but unlikely - harm being caused by the intervention?
“Honesty” is the last principle for discussion within the development of an ethical toolbox in the form of an “aide memoire” for the context of environment and health. To Malone and Zolzer (2016) this means that transparency, truthfulness and accountability are given when developing and implementing interventions.
This seems to be particularly relevant for public and environment and health, given that actors are often professionals in public institutions where trust is essential to maintain credibility and the functioning of public structures. Trust, again, can only be achieved when abiding to honesty. The following questions could thus be formulated:
- • Are the actors proposing or implementing an environment and health intervention, and its implications, in a truthful and transparent manner?
- • Are benefits and risks discussed and presented to the public in a transparent way?
How to apply the “aide mémoire”
We also want to offer some guidance on how one can apply the principles and normative questions as laid out previously in the “aide mémoire.” Thus, decisionmakers of an environment and health institution could consider following these steps to identify whether a proposed intervention contains moral issues, and to work towards finding the best justifiable solution or way forward (indeed, we believe that every proposed intervention shall be assessed in such a way, even if it is not evident that there are ethical issues):
- 1 Consider the intervention at stake, go through the “aide mémoire” and ask the proposed questions: What moral issues related to this intervention do the questions raise? Which ethical principles are at stake? Are they in conflict with each other? Using the language of the norms and values: What is the problem or even the dilemma?
- 2 Check for alternatives: Are alternative solutions feasible with fewer moral issues?
- 3 Weigh and balance: Are all conflicting principles still of equal value? Or can one make trade-offs between principles, accepting that the importance of pursuing one principle at the cost of another is unavoidable (given that no alternative, ethically better acceptable interventions are available)?
- 4 Determine integrity: What does one conclude from the weighing? Can one personally accept the conclusion drawn?
- 5 Act and convince: Act according to one’s own judgement and convince colleagues and others also based on ethical reasoning. Disclose what ethical principles are affected - supported or infringed - by the proposed intervention and how you would balance actions and decisions in the potential conflict to solve the moral challenge or dilemma.
Tools in practice and education
This is but one proposal of an ethical toolbox for environment and health: combining principles broken down to operational and specific questions and with a suggestion, how one can use these principles and normative questions, and to
Ethical tools for decision-makers 165 come to a judgement on actions and decisions. These steps are relevant for justification processes of intervention implementation. However, we do not suggest that this is a tool sufficient for all contexts of environment and health. Indeed, in some contexts, some of the norms and values mentioned in this aide memoire are not relevant at all, while others might be missing. Stakeholders of environment and health might rather prefer other approaches and tools (not based on ques-tions, or not with predefined principles etc.). Thus, this proposal of an ethical tool is only the base for future discussion and development.
Despite such a tool running the risk of being too simplistic, we are convinced that it is better to use such a tool than ignoring ethical questions completely, or making intuitive decisions only. Rather, at least this minimal ethical reflection is important for justification of decisions and actions. Importantly, justification is most relevant in the context of public institutions and actors: One has to be able to convince and explain why one has chosen or will choose an intervention (over another), and here questions of effectiveness are not the only questions at stake, as moral values also play a role.
Our experience of university training in health sciences and/or public health is that ethical training needs more integration, but little time is available to inte-grate ethics into the current curricula. Thus, we suggest teaching tools in short time slots, rather than having no ethical training in bachelor and master programmes at all. However, it would be preferable, of course, to have more time available in which one can also explain ethical theories of justice and autonomy, the theories of consequentialism and so forth, in more depth. Introducing virtue theories would also enrich the understanding of the moral landscape for our future health professionals and decision-makers in environment and health.
The concept of an “ethical tool” seems promising. An ethical tool can make it easier for persons to address and solve a decision conflict and support open discussion. Thus, from a practical point of view, an ethical tool has a positive connotation. On the other hand, philosophical purists might disagree and say that philosophical reflection about practical and moral problems cannot be simplified, and that such tools lead to simplistic mechanisms that give the appearance of easy solutions. However, easy solutions and easy answers do not exist in ethics, otherwise, a question would not even appear for ethical reflection.
Against this tension, we personally conclude that ethical tools cannot be more than starting points for ethical reflection. We need more debate and research about what ethical support decision-makers want and need, and how philosophers can be helpful in improving environment and health practice.
1 Germans in Aachen Get Free Iodine Amid Belgium Nuclear Fears, www.bbc.com/news/ world-europe-41121761.
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