Schröder-Bäck P, Maeckelberghe E, Royo-Bordonada MÁ. The Ethics effect (editorial). SEEJPH 2014, posted: 23 September 2014. DOI 10.12908/SEEJPH-2014-31 1 EDITORIAL The Ethics effect Peter Schröder-Bäck 1-4 , Els Maeckelberghe 3-5 , Miguel Ángel Royo Bordonada 4,6 1 Department of International Health, School for Public Health and Primary Care (CAPHRI), Maastricht University, The Netherlands; 2 Faculty for Human and Health Sciences, Bremen University, Germany; 3 EUPHA Section “Ethics in public health”; 4 ASPHER Working Group on Ethics and Values; 5 Institute for Medical Education, University Medical Center Groningen, The Netherlands; 6 National School of Public Health, Institute of Health Carlos the Third, Madrid, Spain. Corresponding author: Priv.-Doz. Dr. Peter Schröder-Bäck, Maastricht University, Faculty of Health, Medicine and Life Science, School for Public Health and Primary Care (CAPHRI), Department of International Health, Postbus 616, 6200 MD Maastricht, The Netherlands; Telephone: +31(0)433882343; E-mail: Peter.Schroder@maastrichtuniversity.nl mailto:Peter.Schroder@maastrichtuniversity.nl Schröder-Bäck P, Maeckelberghe E, Royo-Bordonada MÁ. The Ethics effect (editorial). SEEJPH 2014, posted: 23 September 2014. DOI 10.12908/SEEJPH-2014-31 2 Moral issues – Also in public health Sometimes researchers and practitioners of public health are confronted with situations where it is not self-evident which option for action is the better choice. A decision about implementing a particular public health intervention can be difficult because there is a lack of scientific evidence that would speak clearly for or against its effectiveness. Moreover, a decision can be difficult because of moral values that are at stake. Indeed, taking a decision might sometimes feel like replacing one evil with another; or at least accepting some restrictions of liberty of individuals in the trade-off for another good, e.g. the health of others. Examples of difficult choices can be to implementing quarantines and isolations (like those being currently in place in relation to the Ebola outbreak in West-Africa), obligatory immunizations, prohibitions of risky behaviour or (re-)distributing resources. Ethics is the discipline in which one asks systematically what the right and good choices are – in life in general, but also in academic and professional fields such as public health. Ethics asks “Why should I do this or that?” and the reply consists of giving reasons and developing an argument. Ethics hereby draws on principles, values and virtues and has developed substantive theories in the last two-and-a-half-thousand years. In medicine, the value of ethics for taking the right choices in the context of professional conduct, deeply rooted in the Hippocratic Oath, has a successful tradition of some decades by now. In the last century the combination of ethical argumentation with medical problems lead to intensive discourses under the name “bioethics” (1). Bioethics, however, focuses on the individual patient and does not (usually) have a public health perspective. Yet, in public health there are, as just mentioned, many ethical challenges that request reasoning about choices. In 2003, Gaare Bernheim carried out a study with public health professionals. She found that public health practitioners “often feel ill-prepared to make the ethical trade-offs and perceive a need for more education and support to make these decisions” (2). Thus, it is no surprise that more and more actors in public health research and practice requested to introduce the discipline of ethics into public health science, practice and education. Schools of public health in the European region asked for more support from their association (ASPHER) to introduce ethics in their schools and curricula, because only some schools do offer ethics training in their bachelor or master programmes (3). Integrating ethics into public health The implementations of difficult public health interventions have usually lacked explicit preceding ethical analyses or had to contend with conflictive and ambiguous ethical principles. Yet, when we started several years ago to advocate introducing ethics into academic European public health discourses (4), we did not only preach to the converted. In fact, the term „ethics‟ also had a negative effect on some public health researchers. Even though many researchers and practitioners applauded the introduction of ethical discourses into public health, we have also quite often heard that ethics is not the most urgently awaited for input for public health research. Colleagues were sceptical because, in their opinion, ethics commissions are the institutions that may hinder proper public health research. Sometimes public health practitioners were doubtful: Can ethics really be helpful? The answer becomes obvious when we realize that no health intervention, including a preventive or health promotion program, is risk-free. Even when the harm caused to a particular person by a public health intervention might be minimal, the impact can be extremely relevant if the intervention is targeted at the population level, most of whose recipients are healthy. Among the opportunities ethics offers when being introduced into public health discourses are reflections about leading values and decision-making criteria, identification of normative loopholes or inconsistencies in argumentation, shifting burdens of proof among actors, and Schröder-Bäck P, Maeckelberghe E, Royo-Bordonada MÁ. The Ethics effect (editorial). SEEJPH 2014, posted: 23 September 2014. DOI 10.12908/SEEJPH-2014-31 3 the like. Among the limits are that ethics does not offer a ready to use algorithm for making decisions and often the feeling prevails that after an ethical discussion one has not a definitive answer or is still confused – but on a higher level (as the physicist Enrico Fermi once formulated it in a different context). The way forward In our perspective, recent developments to establish public health ethics discourses are highly welcome, because of the ethics effect on human practice in general and public health research and practice in particular: having an understanding of what are the reasons for choosing A over B. Ethics can help to identify good reasons and unmask bad reasons. It is through the exchange of arguments, within discourses, through which public health can get (even) better: doing the right thing for the right reason. Because only if it is for the right reason – and not by chance, based on a prejudices or because of following a dogma – one can convince others; as Sen says “bad reasoning can be confronted by better reasoning” (5). And to identify good and convincing arguments is a task of ethics. Thus, ethics can and should be further integrated in public health education, research and practice – but it is still a long way to go until ethics is as well integrated into public health as it is into medicine. Let‟s continue to bring ethical discourses onto the table of public health researchers and practitioners. To contribute to this endeavour, we welcome in this journal articles that have ethics integrated into the public health perspective; or articles that deal with public health ethics explicitly. References 1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 6th Edition. Oxford University Press: New York, 2009. 2. Bernheim RG. Public health ethics: The voices of practitioners. J Law Med Ethics 2003;31:104-9. 3. Aceijas C, Brall C, Schröder-Bäck P, Otok R, Maeckelberghe E, Stjernberg L, Strech D, Tulchinsky T. Teaching Ethics in Schools of Public Health in the European Region – Results of a Screening Survey. Public Health Rev 2012;34:146-55. 4. Maeckelberghe EL, Schröder-Bäck P. Public Health Ethics in Europe – Let Ethicists Enter the Public Health Debate. Eur J Public Health 2007;17:542. 5. Sen A. The Idea of Justice. Cambridge MA: Belknap Press, 2009. ___________________________________________________________ © 2014 Schröder-Bäck et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.