Q&A with President Emeritus Harold Shapiro: Public health and policy–what does it involve?

The full scope of Public Health’s responsibilities is something which is continuously being debated.  Many things come to mind when we think of public health. Compulsory vaccines, combatting epidemics and outbreaks all come to mind. But who makes these decisions? And how are the ethical concerns evaluated and dealt with by the state and federal governments? Additionally, how is public opinion taken into consideration when evaluating the ethics behind key scientific discoveries? Below is a Q&A with Professor Harold Shapiro who is former President of Princeton and professor in the departments of economics and public policy. He has served as the chair of the National Bioethics Advisory Committee established during President Clinton’s administration.  He has dealt with issues of cloning and embryonic stem cell research—two of the most prominent ethical and moral questions raised by developments on the scientific frontier in recent years.

Find out what he has to say about ethical protocols, ethical issues as well as his view of public health and bioethics in the following Q&A.

PPHR: What are the important procedures or protocols that the US federal and/or state government usually follows to address the ethical concerns related to public health policy while forming a policy or a law?

Professor Shapiro: The first question, if I understand it correctly, deals with how governments, whether state or federal governments, regard the ethical issues that might be raised either from new scientific developments or new health policy proposals. In short to they have specific well defined procedures for considering these matters?  My view is they don’t have specific procedures. It doesn’t mean that they don’t do it. They do it inside other more general procedures as they are trying to work through possible changes in regulations and/or the law. Ethical issues might come to their attention or might not come to their attention. But chances are they do come to their attention in most cases. People who are charged with either writing regulations or actually helping to design legislation may or may not take these ethical considerations up. But there is no mandatory checkpoint which says, “Hey, did you carefully consider the ethical issues to insure that any proposed action was responsive to such concerns?  To my knowledge there is no check point like that. If you use an analogy of the Federal Drug Administration (FDA) for approval of new drug, there is a series of steps— you have to have clinical trials, demonstrate its efficacy and so on and these trials have to respect various ethical constraints. There is no analogous mechanism underlying the enactment of many laws and regulations. This may reflect the fact that so many ethical issues are not fully resolved, but in any case the question of how such issues get resolved is an open one. They get handled sometimes while other times they don’t. And as far as I know, there is no specific procedure to consider the ethical issues before going on, and perhaps this reflects at least in part the fact that a lot of ethical issues don’t have a definite answer. That’s the nature of ethics, and in fact we are still arguing about the some of the same ethical issues we have been arguing about for centuries or even millennia.  Again, that’s simply the nature of ethics; it’s not like a theorem in mathematics or a clinical trial or something of that nature. So, to my knowledge there is no special step to deal with the ethical issues before enacting any policy, or regulation.

PPHR: What aspects of ethical analysis drive the formation of public health policy?

Professor Shapiro: There are different approaches to ethics. There is the consequentialist approach as well as other thoughtful approaches to articulating our ethical responsibilities.  And there is no complete agreement on this. Even people who have thought carefully about it have strong disagreements on whether, for example, consequentialism, where our colleague Professor Peter Singer is a very thoughtful proponent or deontological approaches such as Kantian ethics is the right way. There is no agreement on that. When it comes to forming public health policy, there is no standard road map which says that the ethical issues need to be analyzed this way and overall, we lack an agreed upon framework for dealing with the ethical issues. It is largely a matter of discussion and persuasion and someone making a decision at the end. Then if things don’t go well, you make another decision further on but it’s very different from the scientific issues that need to be resolved. It’s very different from trying to decide whether public health should have a narrow or broad definition. That’s a matter people can argue about but for the ethical issues, we have not even agreed upon what framework to use. So it’s largely in the hands of those policy makers who have to deal with this. They can choose among alternative ways to deal with it but there is no standard and agreed upon way of going about it. One of the results of this is that the ethical issues often get left behind.

My own view of public health is rather more expansive than the traditional view and that it goes way beyond compulsory vaccinations, contagious disease issues, all of which are important but to me it goes beyond that—to analyze how existing structures impact the health of different groups. You have to think of Public health in a very broad sense. But the appropriate scope of public health is controversial; some people think public health should be narrowly defined while others think that it should be expansive. I am in the latter category. I think of public health as having to consider and deal with the basic societal conditions that enable people to live a healthy life so for example, the issue of national health insurance is in my view at least in part a public health issue. I also think that inequality is a public health issue. . Progress itself often leaves sections of our society behind thus providing us with the challenge and responsibility of dealing with the health consequences of such progress.  We need to ask ourselves if our society has adequate mechanisms to ensure such corrections over time. Progress, therefore, always can be expected to generate public health issues. I have to acknowledge, however, that in this country for the most part, public health initiatives follow a narrower concept. Hopefully that can change in the future.

PPHR: As the chair of the National Bioethics Commission, what were some of the issues present at the time and the ethical concerns regarding them at the time? What was the final decision and what is your stance on it looking back?

Professor Shapiro: This was a period of where the two most notorious kinds of issues we were dealing with were cloning, since it was the time of the Dolly experiment, and human embryonic stem cell research. I think your question is how we dealt with them. Taking stem cells as an example, what did we do and what kind of analysis did we follow? Well, we knew that for the case of embryonic stem cells that there were irreconcilable differences between people’s views. The destruction of embryonic cells is considered homicide to some and for them it is something which should not be tolerated, or at very least the federal government ought not to back such activities.  Others did not consider the embryo to have such an elevated moral status and thought we had a moral responsibility to pursue such research for the benefits of future generations. These opponent groups were not going to change their minds. So, you are dealing with a contested ethical issues and the society is divided on the issue. In order to deal with this, we asked ourselves the question, “What do we do here? Do we just use our personal perspectives if we have one?” “Do we simply consult our individual conscience? This would not be sufficient since we felt obligated to justify our recommendations in a publically acceptable manner. The way we tried to tackle the issue was to acknowledge that our recommendations would not be accepted by everyone and that our responsibility was to contribute as best we could to the on-going debate, While any recommendation we made would be unacceptable to some we tried to articulate a recommendation that might signal to others hat while we did not share their views we respected them at very least as our moral equals.

For example, in the human embryonic stem cell case, there are various ways of creating embryos. We said we ought to go ahead with stem cell research but only if you use embryos that were created for a reproductive plan. That is only if these embryos were created by couples or individuals in their desire to have children but they came not to need them for whatever set of reasons. So that would at least say to the other side, in our minds, that we did not suggest creating  research embryos in any manner, but only deploy those that were created for a genuine reproductive project but were no longer needed and would be either frozen or discarded. In this way such material would be serving a very important human purpose.  I doubt that any of those on the other side of this debate found our recommendation acceptable, but maybe they thought that at least we heard their arguments and that while we disagreed with them we respected their views.

So my view is that in a society that is divided on ethical issues, you look for a solution that does come down on one side or another, but at the same time at least signals the other side that you have respect for their point of view. That’s how we went about it. Since we came down in favor of human embryonic we did not satisfy those that thought it might be the moral equivalent of homicide, but some may have thought that at least we heard them.

In a pluralistic society like ours, I think that this type of attitude is necessary because there are going to be disagreements on public health and other issues about what is morally appropriate. You can at least hope to find a policy position that shows the “loser,” so to speak, that we respected their views and opinions. That seems to be consistent with the needs of a morally pluralistic society.

PPHR: What are some of the major challenges in creating public health policy? What are your recommendations to overcome those challenges? More specifically, what are your recommendations to address all relevant ethical concerns while formulating any specific public health law or policy?

Professor Shapiro: We can be here all day, all month on this. Overall, my own view is that the major challenge is in the area of inequality—inequality of access to those kinds of health benefits which enable someone to be a fully participating member in society. Without that it’s very hard to think that you can fully participate in the community, contribute to the society and benefit from your contribution. It seems to me that inequality is the big challenge. And I think it is a public health issue. Inequality does drive morbidities in various kinds. And the failure to address this is not only a public health problem but in my mind the biggest public health problem.

And that is to bring, however slowly and perfectly, health benefits to everyone to the extent you can. The inequality of income is one thing but what public health ought to be interested in is not directly the inequality of income but inequality of access to those services that would let each individual maximize his or her potential. That should be the aim. Obviously it is not a perfect world, and we are never going to quite achieve that but we ought to be closer to this than we are now. If you look at our economy in the recent decades you can see this huge and very substantial growth rate. We are a lot better off than we were historically. Nevertheless this has driven a lot of increased inequality. I think that this is the most pressing public health problem we have today.

Again, I don’t know how to address all the relevant ethical concerns. But one of the important issues we have is the question of when you can use the police powers of the states to enforce public health concerns. That remains a controversial and difficult issue and I think that needs a lot of discussion. The most obvious example is compulsory vaccines but if we ever get in an unfortunate position of having to deal with a pandemic of some kind, it would also include isolation of individuals, tracing contacts of individuals and invading their privacy in various ways. I think it’s not so much a direct ethical concern as it is a legal/constitutional issue. While the police powers of the states (which are primarily operating here) can be used in the service of public health, they nevertheless compel people to do things which may be an impingement on their privacy or their constitutional rights; to me, that’s the hardest issue and I don’t know whether to call it an ethical or legal issue. But that’s a very important one which is on my mind. I’m sure there are others but they don’t come to mind right away.

PPHR: The field of bioethics which has been emerged from 1960s in order to include ethics formally into public health policy domain. What are the different types of career opportunities available in the area of bioethics?

Professor Shapiro: Well, bioethics, as you pointed out, is a relatively new discipline even though some of the issues have been thought about for a long time. That’s what the Hippocratic Oath is about and so on. But it is a new area of scholarship and as you quite correctly identified in its current form it emerged in the 1960s. I’m one of those people who don’t think that bioethics is yet an independent discipline. My advice to students who are interested in bioethics is to pursue it in conjunction with a well established discipline or profession in connection with medicine or law or philosophy or history—something where an existing discipline is present so you can ground yourself in a very well established discipline. In my mind, a discipline can only emerge after it has had many decades to reflect on itself and its scholarly output.  I don’t think bioethics is there yet. So my advice to students is to pick a profession or discipline which really interests you, do that, and bring bioethics as a special interest along with it. So you can be a lawyer and be interested in bioethics in law or a historian and think of the history of bioethics concerns. There are a lot of examples. But really situate yourself in a discipline and have that disciplinary strength, which I don’t think bioethics has yet developed despite its many valued contributions to our national life. If you think of the pioneers of modern bioethics, they came from other disciplines; there was no bioethics as a discipline then—in the 60s, 70s and even 80s. I am not even in favor of a bioethics major. I would much rather if students, who were interested, get something like a certificate in bioethics in the Princeton context. We don’t have a PhD program in bioethics at Princeton. Some places do but I don’t think that is a good idea. Do it through medicine or law or sociology or anthropology and so on. Some of the most interesting work for example, is in reproductive technologies and the ethical issues comes out of sociology and anthropology.

Perhaps as decades pass, this will change as bioethics will have had time to reflect on itself in a careful and thoughtful way to emerge as a discipline. So maybe someday, there will be a department of bioethics at Princeton or other places like Princeton. That’s my view while but it’s definitely a controversial matter.

PPHR: When ethicists appeal to “values”, who gets to decide which values are worthy of protection or how these values should be prioritized in cases of conflict? How should ethical analysis address the tension between universal principles and culturally specific values, and find common ground among individuals from diverse cultural backgrounds?

Professor Shapiro: Well, ethical issues can’t always be resolved to everyone’s satisfaction. They can be competing thoughtful approaches that are internally consistent that can be mobilized to deal with an ethical issue. It’s not like a new scientific discovery which replaces all the old science because the new approach has demonstrated itself to be superior. That does not often occur in ethics. In some sense, it’s not clear how you resolve some of these ethical issues. Sometimes you invent procedural ways to come up with a controversial decision. At other times clarifying an issue can resolve a disagreement. However, in some cases disagreements cannot be resolved and we are left with the challenge of productively living together despite our disagreements on certain moral issues.

This is what makes living an ethical life so difficult and challenging. We have to deal with the fact that there are competing views and one doesn’t have any other way out. They are simply there competing for our attention and support.

In addition to all this, there are experiments in psychology which say that many of the ethical decisions which we make, we make without thinking. I don’t know what it’s called—System 1 and 2 or System A and B. We make these ethical decisions so quickly that the brain has no time to process them. We know how fast the brain works and these decisions are quicker than that. So we know we make these decisions without thinking. The whole issue is of what happens during child development, what aspects of culture are they incorporating into themselves and their automatic response system, in which they look at a situation and make a decision on what action to take. Even when we get to those areas where we do have time to think about alternatives, we often still disagree. So there is a lot going on in this area and there is a lot yet to be resolved.

PPHR: Is there anything else that you would like to share with us about public health, public health policy or public health ethics?

Professor Shapiro: I’m sure there are a lot of other things. I want to go back to two things I have already talked about. One is the expansive view of public health and its responsibilities. As I’ve already said, in my view it is the lack of access to health care that enables you to maximize your potential and contribution to society. That is the biggest issue—inequality is the primary stumbling block which is present since we do not have a national health system.

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