3 Questions for Grégory* Aiguier, Chair of the Ethics and Professional Conduct Committee

Since 2022, you have served as Chair of the Ethics and Professional Conduct Committee at Santé publique France. How has your previous experience—and that of the committee members, which has been heavily focused on ethics in healthcare—contributed to the field of public health ethics?

To answer this question, we must first look back at the history of ethics in public health. In this regard, it can be said that ethical reflections on public health practices are relatively recent. Their emergence is traditionally situated within the context of the AIDS years. This does not mean that there had been no reflection or questioning before, but that since those years, citizens’ trust in expertise and in political and health authorities has been called into question, bringing ethical reflections on public health into the public sphere. The scandals involving contaminated blood, mad cow disease, and the drug Mediator—and, more recently, the COVID-19 pandemic—have generated mistrust among some citizens. These experiences have highlighted the importance of ethical reflection, particularly in public health. But public health soon ran into a major problem: the lack of a stable theoretical and methodological framework specific to this discipline. This is why public health has turned to biomedical ethics, healthcare ethics, or bioethics—as other sectors do today, particularly social work—to find sources of inspiration.

It is with this perspective in mind, and by incorporating one of the major dimensions of the development of health ethics—namely, multidisciplinarity—that the CED at Santé publique France includes experts from diverse disciplines (public health, medical ethics, philosophy, law) who participate in ethical deliberation bodies (regional ethical deliberation forums, hospital ethics committees, and working groups at the Council of Europe level). Our disciplinary diversity and our collective experience enable us to propose avenues for reflection on the problems and topics brought to our attention, with the aim of better addressing the complexity of the issues raised.

In what ways do the conditions for action in public health raise specific ethical questions? What has been your role and that of the CED members in driving the pragmatic approach to public health ethics—one that is sustainable and that the agency will implement?

As I mentioned earlier, the development of public health practices is strongly correlated with societal and cultural shifts, which are largely marked by a sense of mistrust toward expertise and toward health and political institutions, whose legitimacy is no longer fully recognized. Added to this is a growing emphasis on autonomy within our Western societies, reflected in particular by the rise of health democracy, which calls for a renewed need for information, transparency, and even—today—participation in decisions and actions that are no longer considered to concern only a few specialists, but all citizens, in all their diversity. All of this impacts practices. The degree of social acceptability of certain public health practices is, in this regard, 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 well-being and the collective good, individual freedoms versus collective constraints (such as lockdowns or the closure of medical and social care facilities), and delegation versus participation.

In this context, the agency has adopted a so-called pragmatic ethical approach. The scope of this approach is far more fundamental than the term suggests. On a philosophical level, and more broadly within the field of the humanities and social sciences, this approach is not limited to purely practical considerations. It is more a matter of contextualizing ethical reflections to situate them within the practical, cultural, and social environments in which so-called problematic situations arise. It is also a matter of reflexivity on the part of the agency’s professionals, not merely to correct practices or comply with predetermined standards (social, technical, moral), but to develop a critical mindset and sensitivity to the problems that may arise from public health practices. The choice of a so-called pragmatic ethics is therefore anything but neutral when considering its implementation within an agency such as Santé publique France. It raises the issue of an ethics integrated into practices—some authors refer to this as “ethical competence”—rather than strictly delegated to a third-party committee composed of experts. As you can see, this choice thus 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 enthusiastic about contributing to this development of ethics, even though we are well aware that the path will inevitably be long and will extend far beyond the scope of our mandate.

The CED’s mandate ends at the close of 2024, and a new CED will be established. What recommendations are there to ensure that this committee supports the Agency in this effort over the long term?

Taking stock immediately after the fact is a delicate undertaking. We are currently working on a “feedback report” that will supplement the annual activity reports and other minutes of CED meetings. This assessment must be viewed in the context of the Agency’s choices regarding the development of ethics. In this regard, remarkable work has been undertaken, whether through the development of the guide “Guidelines for Ethical Analysis” or the organization of three workshops and a summary seminar (1). CED members have actively participated in these initiatives and have appreciated the Agency’s direction regarding its ethical approach.

Nevertheless, it remains necessary to clarify and formalize what the functions, missions, and role of the CED will be within this framework. Personally, I remain convinced of the value of having an ethics and professional conduct committee that meets to rule on problematic situations requiring distance and perhaps a certain degree of objectivity. This in no way detracts from the development of an ethical culture and its integration into the teams’ very practices. But the CED must also evolve to align more closely with the agency teams’ practices. It seems to me that in the future, there will need to be better coordination between agency staff and CED members. . Furthermore, work remains to be done to raise awareness of the CED, its prerogatives, the practical procedures for filing cases, and its positioning within the agency. But make no mistake: this work is not only a matter of information but also of raising awareness and providing training on the ethical approach itself. Indeed, many perceptions—specific to ethics and its implementation within institutions—persist and may raise questions about its true intentions. Is ethics viewed exclusively from a normative perspective of regulating practices, or as a means of supporting teams in developing critical thinking with a focus on accountability and empowerment? It is clear that the positioning of ethics is anything but neutral and that the agency must formalize its ethics initiative. The key word, in my view, remains trust: trust in the ethics initiative and in its institutionalization; trust in the mechanisms and tools deployed to foster ethics; trust in the processing and lessons learned from ethical work; trust in what is made of ethical work. This trust can only be built with the agency’s professionals, who are responsible for actively participating in the implementation of their ethical approach, in line with the agency’s mandate and missions. It seems to me important to recall that the ethical approach is at once an aim (toward the good, toward just action), a practice (of reflection, of discussion), but also a commitment (individual, collective, institutional).