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

Since 2022, you have served as 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 has this shaped 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 that it is only recently that we began to consider the ethical aspects of public health practices. It is generally believed that this reflection began to emerge during the early years of the AIDS epidemic. This is not to say that ethics was never previously considered or explored. Rather, over the years, the public’s trust in expertise and in political and health authorities has been called into question, bringing the issue of ethics in public health into the public sphere. Crises such as the contaminated blood scandal, mad cow disease, the drug Mediator (benfluorex) in France, and, more recently, the COVID-19 pandemic, have fostered mistrust among segments of the public. These experiences all highlighted the importance of ethical considerations, particularly in public health. But public health quickly ran into a major problem: 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 for 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 individuals 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 collective experience serve us well in proposing ways to address the problems and topics brought to our attention, 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 health and political institutions, which are no longer regarded as having the same legitimacy as before. In addition to this, the concept of autonomy is growing in importance in Western societies. This is particularly reflected in the democratization of healthcare, which has sparked renewed demands for information and transparency, extending to a call for participation in decisions and actions that are no longer seen as the exclusive domain of a few specialists, but as a matter of concern for all citizens, in all their diversity. All of this has an impact on practices. In this regard, the extent to which certain public health measures are socially accepted serves as 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 the closure of long-term care facilities), and delegation versus participation.

In this context, the agency has moved toward what might be called pragmatic ethics. The scope of this approach is much broader than the term suggests. From a philosophical perspective, 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 matter of contextualizing ethical considerations to reposition them within the social and cultural environments of practice, where situations deemed problematic arise. It also requires reflexivity on the part of the agency’s staff, so that they can not only adjust practices or comply with predetermined standards (social, technical, and moral standards), but also develop a critical mindset and 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 applied 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 composed of experts. Thus, it becomes clear that this choice even calls into question the place and role of the CED within what is necessarily an institutional project aimed at developing 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 CED’s mandate ends in 2024, meaning a new committee will be formed. What recommendations will help this committee support the agency during this long-term process?

Taking stock in real time is a delicate undertaking. We are currently working on gathering general feedback to supplement the information provided by the annual activity reports and CED meeting minutes. This assessment must be viewed in the context of the agency’s choices regarding the development of an approach to ethics. Remarkable work has been carried out in this regard, such as creating the ethical analysis guide "Repères pour l'analyse éthique" and organizing 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 formalize what the functions, remit, and role of the CED will be in this context. 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 in 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 publicize 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 merely a matter of providing information. We will need to raise awareness of the ethical approach itself and provide training. This is because a number of preconceived notions about ethics and how this concept is applied within institutions persist, so questions may arise about the true intentions behind it. Should ethics be viewed from an exclusively normative perspective of regulating practices, or is it meant 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 formalize its ethics strategy. In my opinion, the key word is always trust: trust in the ethics strategy and its implementation within the institution; trust in the mechanisms and tools used to promote ethics; trust in the application and in the lessons that emerge from ethics work; trust in what is done with ethics work. 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 a goal (to do good, to do it right), a practice (of reflection, of discussion), and also a commitment (individual, collective, institutional).