Laaser U, Schröder-Bäck P. Towards a Code of Conduct for the European Public Health Profession! (Short report). SEEJPH 2016, posted: 11 January 2016. DOI 10.4119/UNIBI/SEEJPH-2016-88 1 SHORT REPORT Towards a Code of Conduct for the European Public Health Profession! Ulrich Laaser1, Peter Schröder-Bäck2,3 1 Faculty of Health Sciences, University of Bielefeld, Bielefeld, Germany; 2 Department of International Health, School for Public Health and Primary Care (CAPHRI), Faculty of Health, Medicine and Life Science, Maastricht University, Maastricht, The Netherlands; 3 Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany. Corresponding author: Dr. Peter Schröder-Bäck Address: Postbus 616, 6200 MD Maastricht, The Netherlands E-mail: Peter.Schroder@maastrichtuniversity.nl Conflicts of interest: None. Laaser U, Schröder-Bäck P. Towards a Code of Conduct for the European Public Health Profession! (Short report). SEEJPH 2016, posted: 11 January 2016. DOI 10.4119/UNIBI/SEEJPH-2016-88 2 Introduction Is the group of public health professionals consistent of other professions such as physicians, nurses, social workers and the like, or should public health professionals define themselves as a distinct profession in their own rights? As of today, in Europe, public health professionals do not build an own profession. Czabanowska et al. (1) define and promote in this journal the formalization of the public health profession, based on the criteria which – following Macdonald (2) – differentiate a profession from an occupation. These criteria include adherence to a code of conduct and altruistic service. From an ethical point of view, both elements are essentially related and both are reflected in the most famous example of a code for a health profession: the ancient Hippocratic Oath (3). For a public health profession we can draw only partly on the Oath as public health deals with populations – not with individual patients – and, therefore, requires population ethics, not medical or bio-ethics, the latter well accepted since the 1980s at least (4). Population ethics What is particularly relevant when we take a social or population ethics point of view? Following e.g. Laaser (5) financial means are in principle never sufficient because the health of population groups is always subject to potential improvement. Therefore, efficiency or cost-effectiveness of interventions gains ethical relevance as resources can be spent only once, and are then not available for alternative use. For this reason, population ethics often adhere to the utilitarian principle. However, it is normatively important to amend the utilitarian calculus, namely that the ‘pursuit of happiness’ for the greatest number must not be achieved by reducing the benefit of any single individual (6). Given the specific prevailing European value tradition of Solidarity (7), an additional amendment may be considered namely, that differences between population groups should not increase by any public health measure but be minimized wherever possible. Another deontological limitation of the utilitarian principle is the respect for the autonomy of persons and their rights (8). In addition, a fundamental moral issue remains in that all decisions on population health level are based on probabilities and statistical lives (9), making possible technologies of assessing interventions – and promoting the giving or withholding of interventions – based on utilitarian cost-effectiveness rationales (10). The utilitarian principle, its ethical limitations and practicability for public health decision-making requires a continuous public health ethics discourse (11). Which principles could nevertheless be identified guiding a public health profession in its decisions on the population’s health? Summarising the ethical literature, Schröder-Bäck et al. (12) proposed seven mid-level principles to be considered: maleficence, beneficence, health maximisation, efficiency, respect for autonomy, justice, and proportionality. Laaser et al. (13) proposed with reference to a specific European heritage the following principles: solidarity, efficiency, participation, equity, subsidiarity, sustainability, reconciliation, and evidence, underlining in addition the component of empathy/altruism which is of essential relevance in the individual physician-patient relationship, as well as in the professional-population realm. With regard to a European dimension, the European Commission published Council Conclusions (14) manifesting four overarching principles: equity, universality, access to good quality of care, and solidarity – critically discussed by Schröder-Bäck et al. (15). From this short account it seems that, in spite of different terminologies used, the following four values can be considered as core for a European framework: solidarity, equity, efficiency and respect for autonomy. The access to good quality of care describes only one of the preconditions of health and can be hardly considered as an ethical principle. Laaser U, Schröder-Bäck P. Towards a Code of Conduct for the European Public Health Profession! (Short report). SEEJPH 2016, posted: 11 January 2016. DOI 10.4119/UNIBI/SEEJPH-2016-88 3 A professional code? Can we build a professional code on this value account? Various aspects are published in volume 36 of the Public Health Reviews (16). In its Recommendation on good governance in health systems (17) in 2010, the Council of Europe promotes codes of conduct for stakeholders in the health sector including effective mechanisms for enforcement and specific clauses on conflict of interest. In 2002, the American Public Health Leadership Society published twelve Principles of the Ethical Practice of Public Health (18) [Table 1]. Table 1. Principles of the ethical practice of Public Health No. PRINCIPLE 1 Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes. 2 Public health should achieve community health in a way that respects the rights of individuals in the community. 3 Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members. 4 Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all. 5 Public health should seek the information needed to implement effective policies and programs that protect and promote health. 6 Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation. 7 Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public. 8 Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community. 9 Public health programs and policies should be implemented in a manner that most enhances the physical and social environment. 10 Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others. 11 Public health institutions should ensure the professional competence of their employees. 12 Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness. Even though the values we mentioned and affirmed above are somewhat reflected in the Code of the Leadership Society, values that seem particularly important for a European perspective on public health – namely solidarity and equity – are not explicitly mentioned. According to Prainsack & Buyx (19), often they are even referred to as opposed to the American thinking. Prainsack & Buyx define solidarity as shared practices reflecting a collective commitment to carry costs (financial, social, emotional, or otherwise) to assist others. Also, the term equity has a long European tradition and has likewise a moral dimension. Inequity refers to differences which are unnecessary and avoidable but, in addition, are also considered unfair and unjust (20). We propose herewith that solidarity and equity are core values that have to be reflected in a European version of a Code of Conduct for public health professionals, operating in a Laaser U, Schröder-Bäck P. Towards a Code of Conduct for the European Public Health Profession! (Short report). SEEJPH 2016, posted: 11 January 2016. DOI 10.4119/UNIBI/SEEJPH-2016-88 4 framework that is also guided by the principles of efficiency and respect for autonomy. With a transnational perspective, Verkerk & Lindemann (21) call in addition for more justice of resource sharing on a global scale, whereas Stapleton et al. (22) talk already about a global ethics. These values would reflect a specific European value dimension in public health conduct. But, what does this mean? If we assume – what we do – that a Code of Conduct is important to function as an explicit normative compass for public health and to help building the public health profession for Europe, then such a Code of Conduct should be formulated and it will help to further professionalization of public health. Professionalization of public health is important to advance public health education, training, and practice. In our opinion, there is no contradiction that the profession of public health consists of members of different other professions – which also have their own values and conducts. Yet, if professions work under the roof of public health, the pillars – the core values – of the house that is built are the common denominators. Making the guiding norms and values explicit is important for the self-definition of the professional field/profession and giving guidance in pursuing a fair and respectful improvement of population health. References 1. Czabanowska K, Laaser U, Stjernberg L. Shaping and authorising a public health profession. SEEJPH 2014, posted: 31 May 2014. DOI 10.12908/SEEJPH-2014-23. 2. Macdonald KM. The Sociology of the Professions. London: Sage Publications, 1999. 3. Available in the original version at: https://www.nlm.nih.gov/hmd/greek/greek_oath.html, and in one of the modern adaptations at: http://guides.library.jhu.edu/c.php?g=202502&p=1335759 (both accessed: September 5, 2015). 4. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 6th Edition. Oxford University Press: New York, 2009. 5. Laaser U. Health, economics and ethical reasoning. J Publ Hlth (Springer) 2005;13:229-30. 6. Rawls J. Theory of Justice. Harvard University Press, 1971. 7. Laaser U, Bjegovic-Mikanovic V, Lueddeke G. Epilogue: Global Health, Governance, and Education. In: Lueddeke G (ed.) Global Population Health and Well-Being in the 21st Century – Towards New Paradigms, Policy, and Practice. Springer: New York, 2015. 8. Sass HM. Introduction: The principle of solidarity in health care policy. J Med Philos 1992;17:367-70. 9. Cohen IG, Daniels N, Eyal N. Identified Versus Statistical Lives: An Interdisciplinary Perspective (Front Matter and Introduction). Oxford University Press, 2015. Available at: http://ssrn.com/abstract=2571392 (accessed: September 10, 2015). 10. Laaser U. Ethical approach in good governance of health systems. Moldovan Journal of Health Sciences 2015;4:66-72. 11. Schröder-Bäck P, Maeckelberghe E, Royo-Bordonada MÁ. The Ethics effect. SEEJPH 2014, posted: 23 September 2014. DOI 10.12908/SEEJPH-2014-31. 12. Schröder-Bäck P, Duncan P, Sherlaw W, Brall C, Czabanowska K. Teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes. BMC Medical Ethics 2014;15:73. DOI:10.1186/1472- 6939-15-73. Laaser U, Schröder-Bäck P. Towards a Code of Conduct for the European Public Health Profession! (Short report). SEEJPH 2016, posted: 11 January 2016. DOI 10.4119/UNIBI/SEEJPH-2016-88 5 13. Laaser U, Donev D, Bjegovic V, Sarolli Y. Public Health and Peace. Croat Med J 2002;43:107-13. 14. Council of the European Union. Council conclusions on Equity and Health in All Policies: Solidarity in Health. 3019th Employment, Social Policy, Health and Consumer Affairs Council meeting. Brussels: 8 June 2010. Available at: http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/114994.pdf (accessed: September 10, 2015). 15. Schröder-Bäck P, Clemens T, Michelsen K, Schulte in den Bäumen T, Sørensen C, Borrett G, Brand H. Public health ethical perspectives on the values of the European Commission’s white paper “Together for health”. Cent Eur J Public Health 2012;20:95-100. 16. Chambaud L, Tulchinsky T (eds.). Ethics. Public Health Reviews 2015;36. Available at: http://www.publichealthreviews.net/ (accessed: September 10, 2015). 17. Council of Europe. Recommendation CM/Rec(2010)6 of the Committee of Ministers to member states on good governance in health systems. 18. Public Health Leadership Society (PHLS). Principles of the Ethical Practice of Public Health, Version 2.2.2002. Available at: http://nnphi.org/uploads/media_items/principles-of-the-ethical-practice-of-public- health-brochure.original.pdf (accessed: September 5, 2015). 19. Prainsack B, Buyx A. Solidarity: reflections on an emerging concept in bioethics. Nuffield Council on Bioethics (NCoB): November 2011; ISBN: 978-1-904384-25-0. Available at: http://nuffieldbioethics.org/wp- content/uploads/2014/07/Solidarity_report_FINAL.pdf (accessed: September 10, 2015). 20. Whitehead M. The concepts and principles of equity and health. European Health for All Series No. 1. WHO EUROPA: Copenhagen 1985 (EUR/ICP/RPD 414 7734r). Available at: http://publicaciones.ops.org.ar/publicaciones/piezas%20comunicacionales/cursoDDS/ cursoeng/Textos%20Completos/the%20concepts%20and%20principles%20of%20equ ity%20and%20health.pdf (accessed: September 10, 2015). 21. Verkerk MA, Lindemann H. Theoretical resources for a globalised bioethics. J Med Ethics 2011;37:92-6. 22. Stapleton G, Schroeder-Baeck P, Laaser U, Meershoek A, Popa D. Global health ethics: an introduction to prominent theories and relevant topics. Glob Health Action 2014;7: 23569. DOI: 10.3402/gha.v7.23569. ___________________________________________________________ © 2016 Laaser 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. http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/114994.pdf http://www.publichealthreviews.net/ http://nnphi.org/uploads/media_items/principles-of-the-ethical-practice-of-public-health-brochure.original.pdf http://nnphi.org/uploads/media_items/principles-of-the-ethical-practice-of-public-health-brochure.original.pdf http://nuffieldbioethics.org/wp-content/uploads/2014/07/Solidarity_report_FINAL.pdf http://nuffieldbioethics.org/wp-content/uploads/2014/07/Solidarity_report_FINAL.pdf