Ethics in public health: what are the challenges for Santé publique France?

3 questions for Grégorie Aiguier, Chairman of the Ethics and Professional Conduct Committee (CED) of Santé publique France.

Since 2022, you have been the Chairman of the Ethics and Professional Conduct Committee (CED) of Santé publique France. Your previous experience, and that of the committee members, has a strong focus on ethics in patient care. How did this inform your approach to ethics in public health?

To answer this question, we should first look at the history of ethics in public health. From this perspective, we can see it is only recently that we began to consider the ethical aspects of public health practices. It is generally believed that this reflection started to emerge during the early years of AIDS. This is not to say that ethics was never previously considered or explored. Rather that, over the years, the trust placed by the general public in expertise and the political and health authorities has been called into question, moving the issue of ethics in public health into the public space. Crises such as the contaminated blood scandal, mad cow disease, the drug Mediator (benfluorex) in France and, more recently, the COVID-19 pandemic, have generated mistrust among a segment of the public. These experiences all highlighted the importance of ethical considerations, particularly in public health. But public health quickly came up against a major issue: the lack of a well-founded theoretical and methodological framework specific to the discipline. This meant that public health had to follow the example of other sectors – I am thinking in particular of social work – and look to biomedical ethics, healthcare ethics or even bioethics to find sources of inspiration. From this starting point, and given that a major aspect of the development of healthcare ethics has been multidisciplinary participation, the CED of Santé publique France has sought people representing a range of disciplines (public health, medical ethics, philosophy, law) to serve on bodies involved in ethical reflection such as regional groups, hospital ethics committees and Council of Europe working groups. The diversity of our disciplines and our cumulative experience stand us in good stead for offering ways to consider the problems and topics brought to us, with a view to taking into account the complexity of the issues raised to the best of our ability.

Do the conditions for taking action in public health raise specific ethical questions? What role did you and the other members of the CED play in driving forward a long-term pragmatic approach to public health ethics for the agency?

As I said, the development of public health practices has been strongly correlated with societal and cultural changes. It is also very largely marked by a sense of mistrust of expertise and of the institutions of health and politics, which are no longer regarded as having the same legitimacy as before. In addition to this, the concept of autonomy is growing in value in Western societies. This is particularly reflected by the democratisation of healthcare, which has generated renewed calls for information and transparency, extending to a demand for participation in the decisions and actions that are no longer believed to be the realm of just a few specialists, but the concern of all citizens, in all their diversity. All of this has an impact on practices. In this respect, the extent to which certain public health measures are accepted socially is a good indicator. There are many examples, including vaccination and the management of recent health crises. These examples illustrate the recurring tension in public health between individual and collective well-being, individual freedoms versus collective restrictions (lockdowns or closure of long-term care facilities), delegation versus participation. 

In this context, the agency has moved towards what might be called pragmatic ethics. The scope of this approach is much more substantive than the term suggests. From a philosophical point of view, and more broadly in the field of human and social sciences, the pragmatic approach is not limited to purely practical factors. It is more a question of contextualising ethical considerations to reposition them in the social and cultural environments of practice, in which situations deemed to be problematic emerge. It also requires reflexivity of the agency's staff, so not only can they adjust practices or comply with predetermined standards (social, technical and moral standards), but they can also develop a critical mind and a sensitivity to the problems that may arise as a result of public health practices. The choice of a pragmatic ethical framework is therefore anything but neutral when used within an agency like Santé publique France. It raises the issue of what some authors call ethical competence – ethics being integrated into our practice rather than strictly delegated to a third-party committee made up of experts. So it becomes clear, this choice even questions the place and role of the CED in what is necessarily an institutional project that aims to develop an ethical culture. We are very excited to play our part in developing this ethical approach, even though we are well aware that the road will no doubt be long and far exceed the scope of our mandate.

The mandate of the CED comes to an end as 2024 closes, meaning a new committee will be formed. What recommendations will help this committee to support the agency during this long-term process?

Taking stock, on the spot, is a delicate undertaking. We are currently working on gathering general feedback to round out the information provided by the annual activity reports and CED meeting minutes. This assessment must be seen in the context of the agency’s choices in terms of developing an approach to ethics. Remarkable work has been carried out in this respect, such as creating the ethical analysis guide "Repères pour l'analyse éthique" and organising three workshops and a summary seminar (1). The members of the CED have played a major role in these initiatives and have been able to assess the agency's direction in terms of ethical strategy.

Nevertheless, we still need to clarify and formalise what the functions, remit and role of the CED will be in this picture. I remain personally convinced of the value of an Ethics and Professional Conduct Committee that meets to decide on situations or problems requiring distance and perhaps, to some extent, an external perspective. This would in no way detract from the development of a culture of ethics that is integrated into the teams' practices. In fact, the CED must also evolve to become more firmly anchored to the practices of the agency's teams. It seems to me that, in the future, we will need to improve coordination between agency staff and the members of the CED. There is also work to be done to publicise the CED, its powers, how to refer an issue to it and its position within the agency. But let us make no mistake, this work is not only a matter of providing information. We will need to raise awareness of the ethical approach itself and offer training. This is because a number of preconceived ideas about ethics and how this concept is deployed within institutions persist, so questions may be raised about the true intentions behind it. Is ethics to be viewed from an exclusively normative perspective of regulating practices, or is it to support teams in developing critical thinking with a view to expanding their responsibility and  empowering them? It is clear that the positioning of ethics is anything but neutral and that the agency must formalise its ethics strategy. In my opinion, the key word is always trust: trust in the ethical strategy and its implementation in the institution; trust in the mechanisms and tools used to promote ethics; trust in the application and in the lessons that emerge from work in ethics; trust in what is done with work in ethics. This trust can only be built with the agency's staff, who must actively participate in implementing their ethical approach, in line with the agency's mandate and missions. It seems to me that it is important to remember that the ethical approach is at once an aim (for good, to do it right), a practice (of reflection, of discussion) and also a commitment (individual, collective, institutional).