ETHICS AND PUBLIC HEALTH INTERVENTIONS

Sammanfattning: Programmatic vaccination and screening are the reasons for this thesis. The practice of public health incorporating medicine’s cognitive contents along with contributions from other fields of human activities is basically a moral enterprise. It is important that limitations from the whole continuum of these interventions are recognized to retain credibility. The changing demands resulting from the dynamics of global altering societies, as well as new priorities due to medico-technical developments, must also be acknowledged.
An epistemic expansion of the evidence-base for public health actions is argued for. ‘Nomothetic’ and ‘idiographic’ are suggested as more neutral concepts instead of ‘quantitative’ and ‘qualitative’ for characterizing the methodological approach. Assumptions about the nature of medical knowledge have from the beginning had an explicit preference for empirical evidence. Natural science is often taken as congruent with medical science, a thought style challenged in the history of public health and from outside the discipline. An integration of nomothetic and idiographic kinds of knowledge, i.e. a true research synthesis, is relevant as evidence-base for public health actions and also needed for a valid ethical analysis in context. In each of the presented four cases, the measles vaccination programme, a hypothetical mass screening for prostate cancer with prostate-specific antigen, a hypothetical risk group screening for Herpes virus type 2 and screening for postpartum depression, the evidence-base is discussed in its Swedish context and with a critical eye to the assumed validity of underlying assumptions. The role of history, collaboration over disciplinary boundaries and virtues, especially prudence, is highlighted as important for attaining a critical distance to what is described as facts.
The casuistic approach is necessary to visualize the complexity and the inherent and sometimes hidden ethical problems of the specific interventions. The principles autonomy, beneficence, non-maleficence, justice and the choice of affected persons then give ethical meaning to the otherwise factual circumstances.The suggested framework for analysis does not involve a general theory of values but is enacted in the middle ground between theories and the details of policy and practice. It is one of many possible ways to structure ethical deliberations. The conclusions arrived at are that measles vaccination must remain voluntary to vouchsafe autonomy and credibility; that screening for prostate cancer and Herpes virus type 2 with available tests come with non-acceptable side-effects especially invoking the principles of beneficence, non-maleficence and justice as solidarity. The EPDS screening for postpartum depression at is questionable. The ethical reservations mainly concern the principles of autonomy and beneficence but also how professional knowledge is inundated by values unwittingly having an impact on a weak evidence-base. An analogy approach is used as a complement to illustrate how demands differ, when new methods or technologies are introduced in health care.