Public health decisions made by the state involve considerable disagreements on the course of actions, uncertainties, and compromises that arise from moral tensions between the demands of civil liberties and the goals of public health. With such complex decisions, it can be extremely difficult to arrive at and justify the best option. In this article, we propose an ethical decision-making framework based on the philosophy of Ubuntu and argue that in sub-Saharan African settings, this approach provides attractive alternative conventions of (...) moral decision-making and a useful language for understanding moral reasoning and ethics. Through its emphasis on humanity, compassion, and social responsibility, Ubuntu (“I am because we are”) has the potential to facilitate solutions to and avert conflicts between individual rights and public health. The use of Ubuntu shifts the moral reasoning and ethics of decision-making from a field of philosophy shaped by the global north, to the everyday values, decision-making, and consequent practices of people in much of Africa. Using examples of Ebola, pandemic influenza, and tuberculosis, we illustrate how Ubuntu can be applied to tackle conflicting ethical problems in public health and medicine. (shrink)

Military physicians are often perceived to be in a position of ‘dual loyalty’ because they have responsibilities towards their patients but also towards their employer, the military institution. Further, they have to ascribe to and are bound by two distinct codes of ethics, each with its own set of values and duties, that could at first glance be considered to be very different or even incompatible. How, then, can military physicians reconcile these two codes of ethics and their distinct professional/institutional (...) values, and assume their responsibilities towards both their patients and the military institution? To clarify this situation, and to show how such a reconciliation might be possible, we compared the history and content of two national professional codes of ethics: the Defence Ethics of the Canadian Armed Forces and the Code of Ethics of the Canadian Medical Association. Interestingly, even if the medical code is more focused on duties and responsibility while the military code is more focused on core values and is supported by a comprehensive ethical training program, they also have many elements in common. Further, both are based on the same core values of loyalty and integrity, and they are broad in scope but are relatively flexible in application. While there are still important sources of tension between and limits within these two codes of ethics, there are fewer differences than may appear at first glance because the core values and principles of military and medical ethics are not so different. (shrink)

Patient and citizen participation is now regarded as central to the promotion of sustainable health and health care. Involvement efforts create and encounter many diverse ethical challenges that have the potential to enhance or undermine their success. This article examines different expressions of patient and citizen participation and the support health ethics offers. It is contended that despite its prominence and the link between patient empowerment and autonomy, traditional bioethics is insufficient to guide participation efforts. In addition, the turn to (...) a “social paradigm” of ethics in examinations of biotechnologies and public health does not provide an account of values that is commensurable with the pervasive autonomy paradigm. This exacerbates rather than eases tensions for patients and citizens endeavoring to engage with health. Citizen and patient participation must have a significant influence on the way we do health ethics if its potential is to be fulfilled. (shrink)

This article challenges the idea that the priority of liberty poses a threat to individual and population health. While acknowledging there are cases in which liberty does indeed pose a threat to the health of individuals and populations, I argue that the tension between liberty and health is overstated and that much can be done to relieve this tension. Indeed, liberty and health can and should be viewed as co-equal values in our broader conception of health justice. My thesis is (...) moderate to the extent it acknowledges limits to the coequal status of these twin values; robust to the extent it conceives legitimate health interventions as the outcome of complex and multiperspectival processes of deliberative testing. (shrink)

In this article, we analyse content from two recent reports to examine how a public health framework to cognitive enhancement is emerging. We find that, in several areas, these reports provide population-level arguments both for and against the use of cognitive enhancers. In discussing these arguments, we look at how these reports are indicative of potentially innovative frameworks—epidemiological, risk/benefit and socio-historical—by which to explore the public health impact of cognitive enhancement. Finally, we argue that these reports are suggestive of both (...) tensions between the bioethical and public health approaches and are also indicative of how these two frameworks can, in part, be seen as complementary. (shrink)

This paper is concerned with how public health policy makers should respond to the public’s perception of risks. I suggest that we can think of this issue in terms of two different models of responding to the public’s view of such perceived risks. The first model I will call the public perception view (PP view) and the second the public good view (PG view). The PP view suggests that the public’s perception of any risks is so important that public health (...) policies should be formulated in direct response to knowledge about them. I will consider two possible ethical arguments that might be offered in support of such a view: the first argument is an autonomy argument and the second a consequences argument. I suggest there are serious problems with both arguments. I then outline an alternative model of public health policy formation that I call the public good or PG model. This model focuses on drawing distinctions between the clinical and the public health context, and argues that most of public health policy is primarily concerned with the creation and maintenance of various public goods. This latter fact means that the PP model is inappropriate for public health policy formation. (shrink)

Center for Humans and Nature, 109 West 77th Street, Suite 2, New York, NY 10024, USA. Tel.: 212 362 7170; Fax: 212 362 9592; Email: brucejennings{at}humansandnature.org ' + u + '@' + d + ' '//--> . Abstract A fundamental question for the ethical foundations of public health concerns the moral justification for limiting or overriding individual liberty. What might justify overriding the individual moral claim to non-interference or to self-realization? This paper argues that the libertarian justification for limiting individual (...) liberty known as the ‘harm principle’ or the ‘Millian paradigm’ is inadequate as a basis of public health ethics and policy. But simply pitting some collectivist value or utilitarian criterion over against individual liberty is not theoretically satisfactory, either. John Stuart Mill himself was not a Millian, in this sense, and his utilitarianism does not pit itself against individual liberty as a situation of balancing conflicting values. A reconsideration of Mill, particularly in light of the later work of Berlin on liberty, points toward a conception of relational liberty that is crucial for public health ethics because it contains within itself the basis for its own moral limitation. CiteULike Connotea Del.icio.us What's this? (shrink)

In target articles for this special issue, Fox et al. report that ethics consultation (EC) practices have not improved significantly since 2000, and question whether the status quo affords patients...

Libertarian paternalism describes the idea of nudging—that is, steering individual decision-making while preserving freedom of choice. In medicine, libertarian paternalism has gained widespread attention, specifically with respect to interventions designed to promote healthy behaviours. Some scholars argue that nudges appropriately balance autonomy and paternalistic beneficence, while others argue that nudges inherently exploit cognitive weaknesses. This paper further explores the ethics of libertarian paternalism in public health. The use of nudges may infringe on an individual’s voluntary choice, autonomy and informed consent, (...) but they are ethically justified when there is a clear public health benefit to the manipulation of choice. (shrink)

The COVID-19 pandemic has both exposed and created deep rifts in society. It has thrust us into deep ethical thinking to help justify the difficult decisions many will be called upon to make and to protect from decisions that lack ethical underpinnings. This paper aims to highlight ethical issues in six different areas of life highlighting the enormity of the task we are faced with globally. In the context of COVID-19, we consider health inequity, dilemmas in triage and allocation of (...) scarce resources, ethical issues associated with research, ethical considerations relating to tracing apps, and exit strategies such as immunity passports and COVID-19 vaccines. Finally, we consider environmental issues in light of COVID-19. The paper also offers some ethical reflection on these areas as many parts of the world contemplate the recovery phase. (shrink)

Concern for human vulnerability seems to be at the heart of bioethical inquiry, but the concept of vulnerability is under-theorized in the bioethical literature. The aim of this article is to show why bioethics needs an adequately theorized and nuanced conception of vulnerability. We first review approaches to vulnerability in research ethics and public health ethics, and show that the bioethical literature associates vulnerability with risk of harm and exploitation, and limited capacity for autonomy. We identify some of the challenges (...) emerging from this literature: in particular, how to reconcile universal human vulnerability with a context-sensitive analysis of specific kinds and sources of vulnerability; and how to reconcile obligations to protect vulnerable persons with obligations to respect autonomy. We then briefly survey some of the theoretical resources available within the philosophical literature to address these challenges, and to assist in understanding the conceptual connections between vulnerability and related concepts such as harm, exploitation, needs, and autonomy. We also sketch out a taxonomy of sources and kinds of vulnerability. Finally, we consider the implications for policy evaluation of making vulnerability an explicit and central focus of bioethics. Our investigation is in the form of a broad survey motivating a research agenda rather than a detailed analysis. (shrink)

Recent advances in our understanding of the human genome have raised high hopes for the creation of personalized medicine able to predict diseases well before they occur, or that will lead to individualized and therefore more effective treatments. This possibility of a more accurate science of the prevention and surveillance of disease also illuminates the field of public health, where the translation of genomic knowledge could provide tools enhancing the capacity of public health authorities to promote health and prevent diseases. (...) But beyond scientific considerations, the use of genomics in public health research and interventions gives rise to several ethical and social issues of great importance. Considering the impact that PHG could have on the future of public health while still paying attention to the uncertainty surrounding the use of genomic databases for the benefit of populations, this article seeks to explore the promise of genomics in public health and the ethical issues that emerge from its application. (shrink)

While the realm of bioethics has traditionally focused on the rights of the individual and held autonomy as a defining principle, public health ethics has at its core a commitment to the promotion of the common good. While these two domains may at times conflict, concepts arising in one may also be informative for concepts arising in the other. One example of this is the concept of a “right not to know.” Recent debate suggests that just as there is a (...) “right to know” information about one's genetic status, there is a parallel “right not to know” when it comes to genetic information that if communicated, could be detrimental to an individual's social or psychological well-being. As new genetic technologies continue to change the nature of genetic testing and screening, it is crucial that normative frameworks to guide and assess genetic public health initiatives be developed. In this context, the question of whether a “right not to know” may also be said to exist for populations on a public health level merits attention. (shrink)

This paper evaluates the content of the syllabi of postgraduate courses on public health ethics within accredited schools and programs of public health in the United States in order to gain an awareness of the topics addressed within these courses. Methods: Data was gathered via the analysis of syllabi of courses on PHE. In 2012, information was requested by e-mail from the 48 schools and 86 PH programs accredited by the U.S. Council on Education for Public Health for 2012. The (...) “Epidemiology and PHE Syllabi” project of the University of Miami also was consulted. A table of topics was drawn up in order to carry out content analysis of the documents. Results: Data was obtained from 25 schools and 36 accredited programs ; 36 syllabi were gathered and 75 different topics were found. Of these, 38 topics were addressed in six or more syllabi and can be grouped as follows: foundations of PHE; autonomy and its limits; infectious disease control; justice; research ethics; health education and promotion; environmental and occupational health; screening; genetics; privacy and confidentiality; and community-based practice and vulnerable populations. Conclusions: The analyzed syllabi show high variability in curricular content. The debate with regard to whether a core curriculum on PHE should be established is ongoing. The results of this work might be of interest for schools and programs of PH in other countries or regions of the world in order to develop or ameliorate their own PHE syllabi. (shrink)

In this article, we explore the concept of a “right not to know” on a population rather than individual level. We argue that a population level “right not to know” is a useful concept for helping to define the appropriate boundaries of public engagement initiatives in the emerging public health genomics context.

Background: Expanded newborn screening generates incidental results, notably carrier results. Yet newborn screening programmes typically restrict parental choice regarding receipt of this non-health serving genetic information. Healthcare providers play a key role in educating families or caring for screened infants and have strong beliefs about the management of incidental results. Methods: To inform policy on disclosure of infant sickle cell disorder (SCD) carrier results, a mixed-methods study of healthcare providers was conducted in Ontario, Canada, to understand attitudes regarding result management (...) using a cross-sectional survey (N = 1615) and semistructured interviews (N = 42). Results: Agreement to reasons favouring disclosure of SCD carrier results was high (65.1%–92.7%) and to reasons opposing disclosure was low (4.1%–18.1%). Genetics professionals expressed less support for arguments favouring disclosure (35.3%–78.8%), and more agreement with arguments opposing disclosure (15.7%–51.9%). A slim majority of genetics professionals (51.9%) agreed that a reason to avoid disclosure was the importance of allowing the child to decide to receive results. Qualitatively, there was a perceived “duty” to disclose, that if the clinician possessed the information, the clinician could not withhold it. Discussion: While a majority of respondents perceived a duty to disclose the incidental results of newborn screening, the policy implications of these attitudes are not obvious. In particular, policy must balance descriptive ethics (ie, what providers believe) and normative ethics (ie, what duty-based principles oblige), address dissenting opinion and consider the relevance of moral principles grounded in clinical obligations for public health initiatives. (shrink)

In this essay I argue that the same considerations that justify the strong commitment to anti-paternalism that has been affirmed in bioethics over the past half century, also calls for anti-paternalistic public health policies. First, I frame the puzzle—why are citizens morally entitled to make unhealthy and medically inadvisable decisions as patients but not as consumers? I then briefly sketch the reasons why bioethicists typically reject paternalism. Next, I argue that those same reasons tell against paternalism in public health ethics (...) as well. Patients do not waive their rights to make medically inadvisable decisions when they leave their physician’s care. James Wilson disagrees. After I sketch Wilson’s arguments for paternalism in public health policy, I then argue, contra Wilson, that public health paternalism is wrong for the same reason that medical paternalism is wrong, and that the prevalence of paternalism in public policy does not mean that paternalism is morally permissible. I discuss the state’s authority to enforce paternalistic policies and I sketch an anti-paternalist vision for health policymakers. To close, I consider several objections. (shrink)

Public engagement in ethically laden pandemic planning decisions may be important for transparency, creating public trust, improving compliance with public health orders, and ultimately, contributing to just outcomes. We conducted focus groups with members of the public to characterize public perceptions about social distancing measures likely to be implemented during a pandemic. Participants expressed concerns about job security and economic strain on families if businesses or school closures are prolonged. They shared opposition to closure of religious organizations, citing the need (...) for shared support and worship during times of crises. Group discussions elicited evidence of community-mindedness, while some also acknowledged strong self-interest. Participants conveyed desire for opportunities for public input and education, and articulated distrust of government. Social distancing measures may be challenging to implement and sustain due to strains on family resources and lack of trust in government. (shrink)

In the near future, experts predict, an influenza pandemic will likely spread throughout the world. Many countries have been creating a contingency plan in order to mitigate the severe health and social consequences of such an event. Examination of the pandemic plans of Canada, the United Kingdom and the United States, from an ethical perspective, raises several concerns. One: scarcity of human and material resources is assumed to be severe. Plans focus on prioritization but do not identify resources that would (...) be optimally required to reduce deaths and other serious consequences. Hence, these plans do not facilitate a truly informed choice at the political level where decisions have to be made on how much to invest now in order to reduce scarcity when a pandemic occurs. Two: mass vaccination is considered to be the most important instrument for reducing the impact of infection, yet pandemic plans do not provide concrete estimates of the benefits and burdens of vaccination to assure everyone that the balance is highly favorable. Three: pandemic plans make extraordinary demands on health care workers, yet professional organizations and unions may not have been involved in the plans' formulation and they have not been assured that authorities will aim to protect and support health care workers in a way that corresponds to the demands made on them. Four: all sectors of society and all individuals will be affected by a pandemic and everyone's collaboration will be required. Yet, it appears that the various populations have been inadequately informed by occasional media reports. Hence, it is essential that plans are developed and communication programs implemented that will not only inform but also create an atmosphere of mutual trust and solidarity; qualities that at the time of a pandemic will be much needed. (shrink)

We argue that an unqualified use of the term solidarity in public health is not only equivocal but problematic toward the ends of public health. The term may be deployed normatively by public health advocates to strengthen the bonds among public health practitioners and refer to an ideal society in which the importance of interdependence among members ought to be acknowledged throughout the polity. We propose an important distinction between partisan solidarity and societal solidarity. Because any moralized belief in a (...) vision of a broad societal solidarity will be a contested political ideal, political reality would limit solidarity based on such a vision to partisan solidarity. An idealized vision of societal solidarity is simply not politically feasible in pluralistic, liberal, democratic societies. However, although societal solidarity is unlikely with respect to any particular policy, it might be hoped for with respect to constitutional procedures that provide boundaries for the agon of the political process. We suggest that moralizing assertions of a solidaristic ideal in a pluralistic society might be counterproductive to generating the political support necessary for public health per se and establishing legitimate public health policy. A pragmatic political approach would be for public health advocates to generate sufficient strong political support for those public health policies that are most amenable to the political and social realities of a time and place. (shrink)

Government food and beverage policies can play an important role in promoting public health. Few people would question this assumption. Difficult questions can arise, however, when policymakers, public health officials, citizens, and businesses deliberate about food and beverage policies, because competing values may be at stake, such as public health, individual autonomy, personal responsibility, economic prosperity, and fairness. An ethically justified policy strikes a reasonable among competing values by meeting the following criteria: the policy serves important social goal; the policy (...) is likely to be effective at achieving those goal; less burdensome options are not likely to be effective at achieving the goals; the policy is fair. (shrink)

Public health communications often attempt to persuade their audience to adopt a particular belief or pursue a particular course of action. To a large extent, the ethical defensibility of persuasion appears to be assumed by public health practitioners; however, a handful of academic treatments have called into question the ethical defensibility of persuasive risk- and health communication. In addition, the widespread use of persuasive tactics in public health communications warrants a close look at their ethical status, irrespective of previous critiques. (...) In this article, we review some ethical objections previously advanced against the use of persuasion in public health communications, and also consider some novel but potentially relevant objections. We conclude that persuasion is ethically problematic in some circumstances and attempt to clarify what these circumstances are. However, whereas persuasion may be ethically problematic in some circumstances, it need not be viewed as intrinsically problematic. (shrink)

This article aims to present 10 years of experience of teaching ethics in a Masters Program in Public Health in Lithuania, and to discuss the content, skills, teaching approach and tools of this programme. In addition, the article analyses the links between ethics and law, identifies the challenges of the teaching process and suggests future teaching strategies. The important role of teaching ethics in countries that are in transition owing to a radically changing value system is emphasised.

Background The emergence of molecular HIV surveillance (MHS) and cluster detection and response (CDR) programs as key features of the United States (US) HIV strategy since 2018 has caused major controversies. HIV surveillance programs that re-use individuals’ routinely collected clinical HIV data do not require consent on the basis that the public benefit of these programs outweighs individuals’ rights to opt out. However, criticisms of MHS/CDR have questioned whether expanded uses of HIV genetic sequence data for prevention reach beyond traditional (...) public health ethics frameworks. This study aimed to explore views on consent within MHS/CDR among critical stakeholders.Methods In 2021 we interviewed 26 US HIV stakeholders who identified as being critical or concerned about the rollout of MHS/CDR. Stakeholders included participants belonging to networks of people living with HIV, other advocates, academics, and public health professionals. This analysis focused on identifying the range of positions among critical and concerned stakeholders on consent affordances, opt-outs, how to best inform people living with HIV about how data about them are used in public health programs, and related ethical issues.Results Participants were broadly supportive of introducing some forms of consent into MHS/CDR. However, they differed on the specifics of implementing consent. While some participants did not support introducing consent affordances, all supported the idea that people living with HIV should be informed about how HIV surveillance and prevention is conducted and how individuals’ data are used.Conclusions MHS/CDR has caused sustained controversy. Among critical stakeholders, consent is generally desirable but contested, although the right for people living with HIV to be informed was centrally supported. In an era of big data-driven public health interventions and routine uses of HIV genetic sequence data in surveillance and prevention, CDC and other agencies should revisit public health ethics frameworks and consider the possibility of consent processes. (shrink)

BackgroundHumanitarian crises and emergencies, events often marked by high mortality, have until recently excluded palliative care—a specialty focusing on supporting people with serious or terminal illness or those nearing death. In the COVID-19 pandemic, palliative care has received unprecedented levels of societal attention. Unfortunately, this has not been enough to prevent patients dying alone, relatives not being able to say goodbye and palliative care being used instead of intensive care due to resource limitations. Yet global guidance was available. In 2018, (...) the WHO released a guide on‘Integrating palliative care and symptom relief into the response to humanitarian emergencies and crises’—the first guidance on the topic by an international body.AimsThis paper argues that while a landmark document, the WHO guide took a narrowly clinical bioethics perspective and missed crucial moral dilemmas. We argue for adding a population-level bioethics lens, which draws forth complex moral dilemmas arising from the fact that groups having differential innate and acquired resources in the context of social and historical determinants of health. We discuss dilemmas concerning: limitations of material and human resources; patient prioritisation; euthanasia; and legacy inequalities, discrimination and power imbalances.ImplicationsIn parts of the world where opportunity for preparation still exists, and as countries emerge from COVID-19, planners must consider care for the dying. Immediate steps to support better resolutions to ethical dilemmas of the provision of palliative care in humanitarian and emergency contexts will require honest debate; concerted research effort; and international, national and local ethical guidance. (shrink)

Intuitively we feel that we ought (to attempt) to save the lives, or ameliorate the suffering, of identifiable individuals where we can. But this comes at a price. It means that there may not be any resources to save the lives of others in similar situations in the future. Or worse, there may not be enough resources left to prevent others from ending up in similar situations in the future. This chapter asks whether this is justifiable or whether we would (...) be better served focusing on public health in the form of preventative medicine. It looks briefly at the supposed difference between benefiting individuals and benefiting populations by considering the difference between interventions aimed at ‘rescue’ and those which are preventative. It then considers the rule of rescue in the health care setting, and looks at some of the reasons stemming from this that we might have for allocating resources to rescue interventions. If these reasons do not provide adequate justification for preferring these types of interventions, then the implication is that our current mode of resource allocation may need to be revised in favour of a more public health-oriented model. (shrink)

Whereas in the 1970s early bioethicists believed that bioethics is an arena for the application of philosophical theories of utilitarianism, deontology, and natural law thinking, contemporary policy-oriented bioethicists seem rather to be keen on framing ethical issues through political ideologies. Bioethicists today are often labeled “liberal” or “communitarian,” referring to their different understandings of the relationship between the individual and society. Liberal individualism, with its conceptual base of autonomy, dignity, and privacy, enjoyed a long period of dominance in bioethics, but (...) it has increasingly come under attack from ideologies promoting a more salient role for concepts of solidarity, community, and public interest. (shrink)

Context: Despite much research on informed choice and the individuals’ autonomy in organised medical screening, little is known about the individuals’ decision-making process as expressed in their own words.Objectives: To explore the decision-making process among women invited to a mammography screening programme.Setting: Women living in the counties of Sør- and Nord-Trøndelag, Norway, invited to the first round of the Norwegian Breast Cancer Screening Program in 2003.Methods: Qualitative methods based on eight semistructured focus-group interviews with a total of 69 women aged (...) 50–69 years.Results: The decision to attend mammography screening was not based on the information in the invitation letter and leaflet provided by the NBCSP. They perceived the invitation letter with a prescheduled appointment as if a decision for mammography had already been made. This was experienced as an aid in overcoming the postponements that easily occur in daily lives. The invitation to mammography screening was embraced as an indication of a responsible welfare state, “like a mother taking care.”Conclusion: In a welfare state where governmental institutions are trusted, mass screening for disease is acknowledged by screening participants as a valued expression of paternalism. Trust, gratitude, and convenience were more important factors than information about benefits, harms, and risks when the women made their decisions to attend screening. These elements should be included in the ethical debates on informed choice in preventive medicine. (shrink)

Recent food emergencies throughout the world have raised some serious ethical and legal concerns for nations and health organizations. While the legal regulations addressing food risks and foodborne illnesses are considerably varied and variously effective, less is known about the ethical treatment of the subject. The purpose of this article is to discuss the roles, justifications, and limits of ethics of food safety as part of public health ethics and to argue for the development of this timely and emergent field (...) of ethics. The article is divided into three parts. After a short introduction on public health ethics, all levels of food safety processes are described and the role that ethics play in each of these levels is then analyzed. In the second part, different models describing the function of food law are examined. The relationship between these models and the role of ethics of food safety is assessed and discussed in the final part, leading to some relevant comments on the limits of the role and effect of ethics of food safety. (shrink)

Informed consent is crucial in research, but potential participants may not all speak the same language, posing questions that have not been examined concerning decisions by institutional review boards and research ethics committees’ about the need for researchers to translate consent forms and other study materials. Sixty US IRBs were contacted, and leaders from 34 and an additional 12 members and administrators were interviewed. IRBs face a range of problems about translation of informed consent documents, questionnaires and manuals—what, when and (...) how to translate , why to do so and how to decide. Difficulties can arise about translation of specific words and of broader cultural concepts regarding processes of informed consent and research, especially in the developing world. In these decisions, IRBs weigh the need for autonomy and justice against practical concerns about costs to researchers. At times IRBs may have to compromise between these competing goals. These data, the first to examine when and how IRBs/RECs require researchers to translate materials, thus highlight a range of problems with which these committees struggle, suggesting a need for further normative and empirical investigation of these domains, and consideration of guidelines to help IRBs deal with these tensions. (shrink)

Epidemiological studies of chronic diseases began around the mid-20th century. Contrary to the infectious disease epidemiology which had prevailed at the beginning of the 20th century and which had focused on single agents causing individual diseases, the chronic disease epidemiology which emerged at the end of Word War II was a much more complex enterprise that investigated a multiplicity of risk factors for each disease. Involved in the development of chronic disease epidemi-ology were therefore fundamental discussions on the notion of (...) causality, especially the question when causal inferences could be justified. In this paper, I shall analyze the implicit normativity of these de-bates. First, I shall give a brief overview of the historical background on which chronic disease epi-demiology emerged and describe how the pioneer studies on smoking and lung cancer became icon of the major challenge that the emerging chronic disease epidemiology was facing: the impossibility of proving that statistical associations reflected causal relations. Next, I shall describe how the develop-ment from the monocausal enterprise of infectious disease epidemiology to the multicausal enterprise of chronic disease epidemiology gave rise to intense discussions of the possible criteria by which to establish causal relationships between a given factor and a particular disease. I shall show how the necessary and sufficient conditions expressed in the so-called Henle-Koch criteria that had proved useful for the 19th century investigations of infectious diseases remained an ideal, although clearly an unobtainable one. Thus, I shall show how 20th century chronic disease epidemiologists on the one hand were searching for a new set of general principles which would provide a logical framework for their investigations, but on the other hand admitted that they would have to accept something more "pragmatic". I shall analyze the various positions in this debate, arguing that the implacability of the debate was due to unrecognized normative issues. I shall argue that many insisted on a distinction between science and application that was untenable, but that due to this distinction the values in-volved in deciding whether or not to act on the basis of a hypothesis were rarely explicitly discussed and the decision therefore continued to appear as a matter of taste rather than the result of a cogent normative analysis. (shrink)

In this paper, it is argued that a pragma-dialectical perspective on advisory health brochures can complement current research in the medical domain and vice versa. Advisory health brochures are characterized as a particular communicative activity type to show how this context influences the argumentative process. It is argued that the quality of argumentation in health communication needs more attention. Insights from behavioural theory and persuasion research may help to detect possibly fallacious manoeuvres.