Population-level bioethics brings unique perspective to questions about health and health care

Harvard is home to a university-wide program in bioethics focused on critical issues pertaining to global and population health. The program brings together scholars and clinicians from throughout the university, including the Harvard School of Public Health and the HMS Division of Social Medicine. Two prominent collaborators in this area talked with HMI World about how population-level bioethics is helping to shape health care policy and discussion around the world. Dan Brock, PhD is director of the Division of Medical Ethics at HMS, and director of the Harvard Program in Ethics and Health. Daniel Wikler, PhD is professor of ethics and population health in the Harvard School of Public Health, and was formerly staff ethicist for the World Health Organization.

HMI WORLD: Can you explain the concept of population-level bioethics and how this has developed within the field of bioethics?   

Dan Brock: “We put this notion of population level bioethics around a group of ethical issues that you only see when you take what we call the bird’s eye perspective of looking more broadly and at larger groups of individuals.” Photo by Leah Gourley

BROCK: The field of bioethics has been focused historically on clinical issues that arise between physician and patient, and between researcher and subject. That leaves out of lot of issues that are important for the health of individuals and of populations. There are issues that you don’t really see if you focus only on a particular interaction between a patient and a physician. For example, you don’t see, in looking at those specific interactions, how health inequalities exist in a particular population or across populations, and you don’t see most of the causes of those health inequalities. Most of those health inequalities come from what are typically referred to as the social determinants of health, and these are factors other than medical care. Therefore, if you only look at the medical care being provided, you miss factors that have a big impact on the health of individuals or populations. We put this notion of population level bioethics around a group of ethical issues that you only see when you take what we call the bird’s eye perspective of looking more broadly and at larger groups of individuals.

HMI WORLD: Who are the people who are exploring health through the lens of population-level bioethics. What professional areas are they in?

BROCK: Bioethics has always been an interdisciplinary field, and population-level bioethics, although it involves a somewhat different group of people, is interdisciplinary as well. This group includes philosophers working in health-related areas, and physicians, particularly in public health, which has traditionally had a broader population focus. The group also includes health economists, demographers, epidemiologists, and lawyers in the area of health and human rights.

HMI WORLD: What are some examples of hypotheses or new policies in which questions that fall under population-level bioethics are being asked?

Daniel Wikler: “Instead of thinking only about health care as a policy issue, and thinking of health as a natural fact, we now understand that what societies do in a variety of areas really affects health itself and also the distribution of health prospects and the expectation of healthy life years.”

WIKLER: Dr. Manas Kaushik has identified an iteresting dilemma facing health authorities in India. Fortifying flour with folic acid is among the more cost-effective interventions to improve population health, reducing the incidence of serious birth defects at very little cost and with almost no negative effects on anyone else. But in India, packaged flour is a bit of a luxury. The poorest don’t buy their flour in packages; they buy it from millers in bulk. So they will not be affected by this new policy; those who will benefit are the relatively more fortunate. Fortification is a “best buy” in terms of health benefits per rupee; on the other hand, it looks like it would increase health disparities. So the ethical question here is whether the step should be seen as an unalloyed win or as something that requires a balancing of two different goals: cost-effectiveness and reduction of health disparities. In other words, there are instances in medicine and public health in which what will produce the most help for the population overall  turns out to be something that increases health disparities. Those who are bent on cost-effectiveness would tend to overlook the effect on health disparities, so the question is whether that is an enlightened point of view. In this instance few would advocate holding back on fortification of flour, but the hidden maldistribution of benefits underlines the need to find other ways to bring these benefits to the very poorest.

BROCK: Another example is WHO’s “3 by 5” initiative to provide antiretroviral therapy to people infected with HIV. A host of distributive issues arose. It would be most cost-effective to concentrate on patients in urban areas, where it would be much cheaper because there is already health infrastructure in place, than to go out into rural areas and treating patients there. But is that a fair policy, to essentially abandon rural patients because it is not cost-effective to treat them? We have seen a similar example in Thailand, where we are working with the Ministry of Public Health. They are interested in adding renal replacement therapy, essentially dialysis, to their health insurance plan that treats the majority of the population, including most of the poor. That treatment is now covered in the two other insurance plans that exist in the country. The government cannot cover the cost of dialysis for everyone, so we have been helping them explore the ethical questions around their decision regarding to whom they should make the treatment available.

HMI WORLD: On the issue of who is responsible for our health, many of the sub-topics of population level bioethics refer to our own responsibility, such as whether we exercise or smoke. On the other hand, there are clearly instances in which one is powerless to change where he or she lives, for instance next to a polluted factory, the conditions under which one lives, and other factors contributing to health.

BROCK: Right, we can’t look after our health on our own. On the other hand, the society could reasonably be worried about the fact that poor people end up next to factories and wealthier people can move away and be immune to those risks. So that is an issue of distributive justice. The society ought to recognize this as an issue of distributive justice in the way it concentrates those environmental health risks on the poor. We will be holding a major conference on responsibility for health next year.

WIKLER: The question about personal responsibility is partly a question about distributive justice also, because one of the pressing issues here is that if I act in ways that bring on illness that could have been avoided if I’d acted differently, then whose job is it to offer support or to pay the bills? That’s a question of the distribution of burdens and benefits just like any other.

BROCK: Many of us involved in population level bioethics have worked in developing countries, where the role of poverty as well as other social factors affecting health becomes both acute and evident, and so the concern with the distribution of inequalities of health is especially pressing. The inequalities in health are often greater in developing countries than they are in developed countries.

WIKLER: And the approach to international health, especially in the developing countries where the burden of disease is highest, is almost always a population level approach when it is addressed by organizations like WHO or USAID.  

HMI WORLD: One of the questions that population-level bioethics raises is what should make us more concerned, the disparity between the wealthier and less fortunate, or the actual effects of being less fortunate?  

WIKLER: And which of the effects of being less fortunate can be chalked up to the individual’s responsibility, and which are social or commercial?  These are complex questions. A recent innovation in health policy in the U.S. brings this question right to center stage. The state of West Virginia, after requesting and receiving from the federal government a waiver on Medicaid rules, is going to cut back on the officially mandated package of benefits under Medicaid and offer a very basic package. But they’re also going to offer an augmented  package on the condition that beneficiaries sign a contract promising to take responsibility for their own health. This requires, among other things, compliance with their doctors’ recommendations, and also taking steps to avoid health hazards like tobacco and alcohol. If the individual doesn’t fulfill his or her part in the contract, then the enlarged package of benefits would be withdrawn. This brings up a whole host of both theoretical and obviously practical issues related to ethics.   

HMI WORLD: In addition to ministries of health and other public health agencies, what are the forums where population-level bioethics is being discussed?

BROCK: In health care systems that have a lot of different organizations that are involved in thinking about the health of the population, ethical questions arise. This includes organizations that have a worldwide scope, organizations like Brigham and Women’s Hospital and Massachusetts General Hospital that have a more local scope, and then, in effect, everything in between. For example, currently we have both hospitals and state agencies preparing for a possible avian flu pandemic. Also, ethical questions arise when insurance providers are considering what they are going to cover. These kinds of allocation issues arise at every place within the health system, and in other countries. In Great Britain, for example, there is a body called the National Institute for Clinical Excellence which evaluates new technologies, such as drugs and medical devices, on the basis of their cost-effectiveness and the cost to add another year of healthy life using this intervention. The National Health Service follows their evaluation in deciding whether or not to cover the cost of new interventions.

WIKLER: A number of faculty here have been asked to make proposals in other countries that are developing health insurance programs. When they do this, the ethical issues hit them right away. Should they emphasize catastrophic insurance for unusual high-expense illnesses, and then count on household budgets to cover the routine expenses? Or should they cover the low-cost services so that everyone is assured of low-cost and perhaps sometimes more cost-effective interventions, even though this may leave them unprepared to pay for high-cost interventions? How much should the question of life or death count relative to the question of ability to work or pain and suffering?   

HMI WORLD: One of the questions you approach in population level bioethics has to do with cost-effectiveness analysis. What does it offer to policymakers, and what are the ethical questions it elicits?

BROCK: Cost-effectiveness analysis is an analytic tool that helps determine how to maximize health benefits with a limited pool of resources. From our perspective, when working with someone who is utilizing this tool, our role is to take the analysis and identify what equity issues have been excluded, or what particular position the analysis takes that needs to be justified. This might include questions such as whether one wants to give special priority to those who are worst off, or the justification for using discount rates that disadvantage preventive programs whose benefits are in the future. Do we want to take account of other economic impacts of health interventions, or do we want to focus only on the impact on the health of the population of resource prioritization? A number of people in this field are working in both developed and developing countries to inform resource allocation decisions by helping policymakers understand the ethical issues that are left out of the they receive from economists, and how they can take account of those issues when they make overall policy decisions.

WIKLER: The notion that cost-effectiveness analysis itself is a neutral mathematical exercise is an illusion. There are ethical choices and assumptions that have to be made in the course of doing cost-effectiveness analysis, and it’s important that they be recognized as such. It is standard to discount future health care costs for obvious reasons, such as inflation, but it’s not so clear that one should discount the value of future health benefits. For example, let’s look at the recent controversy surrounding the vaccine for the virus that causes cervical cancer. The vaccine may not avert death from this disease until decades after its administration. If you apply a standard discount rate to the benefits—that is, the deaths that are averted decades later—then their present day value will be very low, possibly leading to the decision to use available funds for other purposes.

BROCK: So the implication might be that you give higher priority to preventing a hundred deaths now than to preventing three hundred deaths in thirty years. That seems to us a problematic policy because the decision is to prevent far fewer deaths.

HMI WORLD: How has the perspective offered by population-level bioethics been received by other ethicists or by clinicians? Has there been resistance? 

BROCK: If people perceive that what we’re saying is that the clinical issues one has concentrated on in the past aren’t important, then they could justifiably be resistant. But what we really want to do is broaden the discussion by supplementing clinical work with this new perspective. We have had a positive response from people who see the benefits of that broader perspective. People see a group of new issues opening up to them.

WIKLER: We have the experience of having collaborated with the World Health Organization as it worked to analyze the global burden of disease, including working through the ethical issues that arose regarding how to measure population health. But many bioethicists have not yet had that experience in which their clinical perspective is paired with the population level view.

During this discussion we have probably touched on a quarter of the issues related to population-level bioethics. It’s a broad agenda ranging from population genetics to the distribution of risks and health decision-making and policymaking, to environmental questions and a host of other things. A lot of these issues, although their importance is recognized, have not been conceived of as questions of ethics or justice. They have been viewed as policy questions demanding the best solution possible. That is just beginning to change, and it’s a two-way process of accommodation. The people who work in the fields of ethics have to learn enough about these clinical issues to be able to say something useful. And on the other hand, the people in the clinical fields have to reframe their understanding of their own dilemmas and see the extent to which they are ethical and not just technical choices. Once we have of that kind of recognition, on each side, we can make better progress.

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