Bioethics Forum Essay
Should Ethicists Be at the Table in Public Health Policy Deliberations?
In a recent article in The New England Journal of Medicine, Ezekiel Emanuel and colleagues clearly illustrate the relevance of ethical considerations to policy deliberations concerning public health emergencies. They rightly point out that scientific evidence alone cannot guide policy decisions, which necessarily involve values and norms and, often, tradeoffs between them.
The second half of the article moves quickly to an assertion about the role that ethicists ought to play in the public health policy arena, as reflected in the following two quotes. “The agencies responsible for responding to public health emergencies need to have trained ethicists on staff, regularly participating in scenario planning and advising.” And, “Ethicists should be at the table when policies are formulated, rather than merely serving as external critics.”
The authors offer no explicit argument to back up these assertions. Perhaps they thought it obvious that ethicists should be at the policy table, given the pertinence of ethical considerations; however, the latter does not entail the former. That ethical values and tradeoffs are inherent in the public health policy arena implies that ethics, so to speak, ought to be at the table. But having ethicists at the table is not necessary, and it may or may not be desirable for relevant ethical considerations to receive due attention in policy deliberations. Moreover, ethicists can play a valuable role in informing public health policy in other ways, and not limited to being “external critics.” Ethicists undertake policy-related scholarship devoted to examining the values at stake in particular policy contexts and arguing in favor of particular policy choices—work that is increasingly published in leading biomedical journals. And ethicists can and ought to be involved in the academic education of professionals, including epidemiologists and public health practitioners, who are destined to be at the table in public health policy deliberations. Ethicists can also serve as ethics consultants called in to give advice to policymakers who are puzzled about how to address the ethical considerations at stake in their deliberations.
Whether ethicists should be at the table is a debatable question, and worthy of being debated, both by ethicists and policymakers. While I do not take a stance on this issue, I suggest that the debate ought to consider reasons why it might be better that ethicists do not serve as staff at the policy table. For example, it might be argued that a staff person hired for ethics expertise might be regarded by other policymakers as providing authoritative guidance on complex ethical issues, which are not subject to consensus among ethicists. In any case, ethics is, or ought to be, everyone’s business, especially with respect to public health emergencies, owing to their pervasive societal and global impacts brought to light in the current pandemic. We need policymakers with ethical sensitivity and openness to competing views about how to resolve ethical problems, regardless of whether ethicists are at the table.
If, all things considered, ethicists should be at the table, this poses additional questions. Do current practices of educating bioethicists prepare them for being effective and responsible agents in the policy arena? If not, as I suspect, how should education of bioethicists be augmented so that they are equipped with the relevant knowledge and skills to function well in that arena?
Franklin G. Miller, PhD, is a professor of medical ethics in medicine at Weill Cornell Medical College, and a Hastings Center fellow and board member.
I appreciate this post and the question(s) it raises. While I understand you are not taking a position, two features occur to me: 1. there are bioethics graduate programs that specifically educate/train in areas of health policy and ethics (I am completing a doctorate in just such a program at Albany Medical College, Alden March Bioethics Institute) and 2. it seems reasonable to have an ethicist communicating directly “at the table” as avenues of discussion and policy direction related to right action, not initially considered, may delay best practice in health policy development and improvement.
Thank you for your thoughts on this topic. As an attorney specializing in advice related to human research activities most often involving clinical care and services, I find it useful and important to be “at the table” during policy discussions, e.g., protocol development. Ethical concerns often illuminate legal and regulatory requirements and can offer sometimes modest changes to goal-directed procedures. Being “at the table” ensures that the context for decision making is transparent, which often makes both ethical and legal-regulatory advice more helpful in formulating outcomes. If trade-offs are involved, which they almost always are, the outcome can and in my experience does reflect the ethical dimensions of decision making. Moreover, ethics becomes integral to the policy making process, rather than a retrospective exercise, which your comment seems to imply.
While you did not claim a stance, some of your responses seem highly skeptical of Emanuel and colleagues’ suggestion of having ethicists at the table. Particularly, in response to the authors’ recommendation of including ethicists in the real-time process: “The authors offer no explicit argument to back up these assertions.” I actually found their arguments – though brief – to be both strong and clear. Although policymakers claim to prioritize “fair and equitable” decisions, the resulting policies often lack the ethical values they intended to include. This (physical and metaphorical) space is where the authors propose ethicists should be placed to provide the frameworks for and implementation of these desired goals. Your counterargument was that ethicists are not competent enough to be effective in this role, to which I disagree, as many ethicists are dually-trained in ethics and public policy, law, etc. These ethicists could provide useful ethical insight while still appreciating the legal and regulatory issues that may arise. Ethicists on staff in these critical moments could prevent the very problem Emanuel, Ross, and Maxwell identified.