公共卫生决策中的伦理框架:捍卫基于价值的多元主义方法。

Ethical Frameworks in Public Health Decision-Making: Defending a Value-Based and Pluralist Approach.

作者信息

Grill Kalle, Dawson Angus

机构信息

Department of Historical, Philosophical and Religious Studies, Umeå University, 901 87, Umeå, Sweden.

Centre for Values, Ethics and the Law in Medicine (VELiM), University of Sydney, School of Public Health, Sydney, NSW, 2006, Australia.

出版信息

Health Care Anal. 2017 Dec;25(4):291-307. doi: 10.1007/s10728-015-0299-6.

Abstract

A number of ethical frameworks have been proposed to support decision-making in public health and the evaluation of public health policy and practice. This is encouraging, since ethical considerations are of paramount importance in health policy. However, these frameworks have various deficiencies, in part because they incorporate substantial ethical positions. In this article, we discuss and criticise a framework developed by James Childress and Ruth Bernheim, which we consider to be the state of the art in the field. Their framework distinguishes aims, such as the promotion of public health, from constraints on the pursuit of those aims, such as the requirement to avoid limitations to liberty, or the requirement to be impartial. We show how this structure creates both theoretical and practical problems. We then go on to present and defend a more practical framework, one that is neutral in avoiding precommitment to particular values and how they ought to be weighted. We believe ethics is at the very heart of such weightings and our framework is developed to reflect this belief. It is therefore both pluralist and value-based. We compare our new framework to Childress and Bernheim's and outline its advantages. It is justified by its impetus to consider a wide range of alternatives and its tendency to direct decisions towards the best alternatives, as well as by the information provided by the ranking of alternatives and transparent explication of the judgements that motivate this ranking. The new framework presented should be useful to decision-makers in public health, as well as being a means to stimulate further reflection on the role of ethics in public health.

摘要

已经提出了一些伦理框架来支持公共卫生决策以及对公共卫生政策与实践的评估。这是令人鼓舞的,因为伦理考量在卫生政策中至关重要。然而,这些框架存在各种缺陷,部分原因是它们纳入了大量的伦理立场。在本文中,我们讨论并批评了詹姆斯·奇尔德雷斯和露丝·伯恩海姆所提出的一个框架,我们认为该框架代表了该领域的最高水平。他们的框架区分了诸如促进公共卫生等目标,与追求这些目标时的限制条件,比如避免对自由的限制的要求,或者保持公正的要求。我们展示了这种结构如何产生理论和实践问题。接着,我们继续提出并捍卫一个更具实用性的框架,该框架在避免预先承诺特定价值观及其权重方式方面保持中立。我们认为伦理正是此类权重的核心所在,我们的框架就是为体现这一信念而构建的。因此,它既是多元主义的,也是基于价值观的。我们将我们的新框架与奇尔德雷斯和伯恩海姆的框架进行比较,并概述其优势。它的合理性在于促使人们考虑广泛的备选方案,并倾向于将决策导向最佳备选方案,还在于备选方案的排序所提供的信息以及对推动这种排序的判断的透明阐释。所提出的新框架对公共卫生决策者应是有用的,同时也是激发对伦理在公共卫生中的作用进行进一步思考的一种方式。

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