(upbeat music)
- [Jane Williams] Hi there, I'm Jane Williams.
In this week's podcast,
I'll be interviewing Dr Bridget Haire,
who lectures in public health ethics and bioethics at UNSW.
We'll be talking about some of the core concepts
in public health ethics.
This will reinforce your understanding of the readings
and the lectures so far
and introduce some new examples
that will help you think more laterally
around the role of ethics in public health.
And also to think about how public health operates
as a moral enterprise.
Hi, Bridget.
- [Bridget Haire] Hello, Jane.
- [Jane Williams] Bridget, at this stage of the course,
what are the key concepts for students?
- [Bridget Haire] Well, public health ethics is concerned
with ethical decision making in the social realm.
So, rather than being about 'the good',
or the best interest of the individual patients,
or research participants,
it's all about populations and communities.
- [Jane Williams] Right, and populations and communities
don't always have uniform ideas
or shared values about what's good.
- [Bridget Haire] That's right.
And even when there are shared values,
they might change over time in response
to different pressures or different circumstances.
- [Jane Williams] Hm, can you give me some examples?
- [Bridget Haire] Yeah!
I'll give you two examples, one that's international
and one that's very local.
So, the first one is voluntary HIV testing.
Now, while there are some circumstances
where HIV testing is mandatory,
like if you want to immigrate to Australia for example,
international policy have generally respected
the importance of individuals deciding voluntarily
when or whether to have an HIV test.
- [Jane Williams] Huh, and why is that?
- [Bridget Haire] It's because there's evidence
of severe social harms occurring in some settings
when people tested positive to HIV.
So, stigma and discrimination but also violence,
people being thrown out of their homes.
And this was particularly evident
again, in some particular settings
where women got diagnosed with HIV during pregnancy
and they communicated this to their untested husbands.
- [Jane Williams] Ah, so the women
were assumed to have brought HIV into the relationship?
- [Bridget Haire] Yeah, that's what, that was the theory.
And despite the fact that they may have very well
acquired the HIV from their husbands,
their husbands weren't tested.
- [Jane Williams] Huh, and has that changed now?
- [Bridget Haire] There are definitely more questions
being asked about the relevance of what they call
HIV exceptionalism because now there are
effective antiretroviral drugs
that can reduce HIV in the body
to where it gets to a point where it can't attack
the immune system and can't infect a sexual partner.
And global access is much better.
- [Jane Williams] So, the argument is
that everyone should get tested
and put on treatment.
- [Bridget Haire] Yeah, that's the
public health argument now.
And in a perfect world, it'd be a really persuasive one.
But the problem is the stigma
and discrimination still linger.
And so the social harms that the strictly voluntary
codes were designed around, do still occur,
I'm sorry to say.
And the ethical solutions then, involve working
to combat HIV related stigma at societal levels
and advancing the rights of people with HIV
so that a diagnosis doesn't impact on your rights.
And then continuing to promote the voluntary
uptake of testing.
- [Jane Williams] Hm, right.
So, what about that local example?
- [Bridget Haire] Well, in Sydney,
we have laws that get called the lockout laws.
These are laws that got adopted
after two young people were killed
in one punch attacks in entertainment districts
within two years of each other.
And, this resulted in laws
that closed premises early.
The last time that people could be let in
was 1:30 AM and the last drinks were at 3:00 AM.
All of these laws was to reduce
alcohol related violence in Sydney's
central entertainment districts.
And there's real evidence that these worked.
But five years after the introduction
following a review of the laws,
the premier announced that the laws will be removed
in most areas of the central business district
with the exception of King's Cross.
So, that's actually the area
where the two young people got killed.
This change has been brought about by economic
and social pressures.
Businesses involved in what they call
the night time economy, argue that they suffered.
And various communities argued that the laws
had a detrimental effect on social life.
And also the reputation of Sydney
as an international city.
- [Jane Williams] Hm, what's going on with the change?
Is the assumption that the problem with alcohol
related violence is gone?
- [Bridget Haire] Not really.
The news reports say that intercity hospitals staff
don't want the laws repealed.
The change appears to be all about a shift in values.
So, in 2014 when the liquor amendment bill 2014
was introduced, it happened just after the second
young person, his name was Daniel Christie,
died after being assaulted outside a nightclub
in King's Cross.
So, six years after that, that loss is no longer
in the forefront of the public's mind
and the economic and social costs
of the restrictions are clearer.
So, ultimately, as the proximity
of the two untimely deaths recede in both the public
and, I would say, the political imagination,
a shift in the weighting of values can be perceived.
So, other factors come to be valued
more highly than the 2014 imperative
to do something to reduce the alcohol related violence
and the tragic, avoidable deaths.
- [Jane Williams] Hm, that's really interesting.
You've talked a lot about law here,
how does the law issue relate to public health
and public health ethics?
- [Bridget Haire] As we've talked about in the lectures,
there's a relationship between ethics and law.
The outcome of the deliberative processes
that involve ethical reasoning in public health
are frequently then, adopted as policies,
regulations, or laws.
So, in the case of the lockout laws,
they impose barriers to alcohol related violence
by restricting and controlling access
to venues and alcohol consumption within them.
And the compliance was enforced.
So, these laws tackled an identified
public health issue through legislation.
And, I would argue that it's the decision making
around the issue where the public health ethics
comes in about how serious the issue is,
how do we rate the drop in alcohol related violence
in comparison with the reduction of economic benefits
for the night time economy.
And the questions of are the laws proportionate
and are they acceptable to the communities
that they impact?
And that's the kind of dialogue that's arguably resulted
in the proposed changes.
- [Jane Williams] Also, different communities
having different priorities or different ideas
of what's good is one of the things that public health
ethics wrestles with.
- [Bridget Haire] Absolutely.
And the principle of justice is very important.
- [Jane Williams] Ah, justice.
Whose justice?
And who defines what's just?
- [Bridget Haire] (laughs) Good question.
As students will have learned in the social determinance
lecture, social justice is critically important
to public health ethics because when you effectively
address the health issues for the worst off,
that's where you get the biggest health gains.
- [Jane Williams] So, are you saying that public health
ethics skews toward egalitarianism?
And that's at odds with old fashioned authoritarian
public health practices like quarantine and isolation
and other mandatory interventions, right?
- [Bridget Haire] Yeah, you're right.
Public health ethics is a relatively new field.
So, it's branched off from bioethics.
And considering how to reach aspirational goals,
like health for all, within a context where there's both
an understanding of the power of social determinence
and an understanding that, as a last resort,
the state can use its coercive powers to compel obedience.
- [Jane Williams] Yeah, so that's the extreme end
of public health powers.
But public health is mostly about very ordinary
health measures rather than wild, terrifying pandemics
that threaten life on Earth.
- [Bridget Haire] Yeah (laughs).
So, public health ethics is often focused
on how to balance a desirable health outcome
for a population with how much interference
in life choices for, communities deem acceptable.
- [Jane Williams] So, what about the idea
that public policies that constrain individuals
supposedly for their own good,
produce a nanny state?
- [Bridget Haire] Yeah, that is a really common
criticism of public health interventions
like the lockout laws particularly.
Another good example is the laws in New York
that ban the sale of a particular mega sized soft drink.
And laws in Australia that mandate bicycle helmets.
Laws like this get criticized particularly
by hard core libertarians for imposing restrictions
on individuals for their own good
instead of giving them the liberty
to make their own decisions.
And, you know, their own bad decisions.
As you know, Jane, the mid-nineteenth century
philosopher, John Stuart Mill, is often invoked
to support the idea that individuals should be able
to make bad decisions if they want to.
And he offered the oft cited harm principle
which states, the only purpose for which power
can be rightfully exercised over any member
of a civilized community against his will
is to prevent harm to others.
Now you know that quote too of course.
- [Jane Williams] Yeah, yeah.
And I feel like the,
it's used a lot.
- [Bridget Haire] Yes (laughs).
- [Jane Williams] Particularly, I find, in Australia,
the kind of nanny state accusation is thrown
around quite a lot.
And it occurs to me that it must be quite,
I supposed, quite culturally or politically specific
to some countries and not others.
- [Bridget Haire] Yeah, Yeah.
And the idea that, of, even what a nanny is as well.
And I guess (laughs), culturally specific isn't it?
And so, I guess like the really, the critical thing
that Mill is saying and the reason that it gets quoted
just so often, I think, for a whole lot of people
it's the only John Stuart Mill they ever read
in their whole lives.
Over himself, over his own body and mind,
the individual is sovereign.
Which is the whole basis,
- [Jane Williams] It is.
- [Bridget Haire] Of liberalism, as well as libertarianism.
- [Jane Williams] But there's kind of an interesting clash
I think with public health there as well
because you've got the idea of,
"I can do whatever I want,
"I can make my own bad decisions,
"Leave me alone.
"But, when it all goes horribly wrong,
you're gonna help me right?"
(laughs)
- [Bridget Haire] Yeah (laughs).
- [Jane Williams] Yeah, it's kind of an interesting,
and not necessarily very coherent contrast
I think, quite a lot of the time.
- [Bridget Haire] Yeah, definitely.
And I think, oh the other thing
that I want to point out is that I think
these days, John Stuart Mill would be very, very embarrassed
about the sexist language because he wasn't a sexist,
he was a fantastic, you know, feminist.
He really was, yeah.
But, that language is still reflective.
- [Jane Williams} Yeah, yeah, Yeah.
- [Bridget Haire] The syntax of the time
I guess, what formal language was.
- [Jane Williams] Of course we will.
- [Bridget Haire] Obviously we will avoid that
in this course.
- [Jane Williams] Thanks Bridget.
Super interesting.
See ya.
- [Bridget Haire] Thank you Jane. Talk to you again soon.
Bye.
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