Summary of the impact

Professor Angus Dawson's research in public health ethics has

a) had a direct, global impact on public health policies, frameworks and interventions

b) contributed to improving the quality of decision-making about public health interventions.

His research has influenced the World Health Organisation's policy on the treatment of tuberculosis, Ontario's public health policy, the US Federal Agency's policy on the preparedness and response to public health emergencies, and a British Medical Association position paper on universal childhood Hepatitis B vaccination. Dawson's research has sought to define the nature of public health, the boundaries of ethical deliberation, and has introduced values, such as the `common good', to supplement the previous narrow range of values that tended to focus on individuals.

Underpinning research

Dawson's research has been instrumental in the field of public health ethics, both in the emergence and definition of this field and in the substantive development of a series of ethical frameworks for policymaking in public health. His central argument is that it is essential to explore the relevant ethical issues within the context of public health as a practice, rather than adopting the dominant approach drawn from medical ethics. The main thrust of Dawson's research has been: (1) to draw out the unique aspects of ethical decision-making in public health interventions and policy, and (2) to provide an approach to developing ethical frameworks through which public health ethical decisions can be made.

(1) Defining Public Health Ethics:

Dawson's work focuses on articulating an account of public health ethics that builds upon both an account of `public health' as a concept, as well as the values that are visible in public health as a practice. Dawson argues that our account of public health ethics should be of practical and operational use in public health decision-making, and should not just uncritically employ values from elsewhere (such as medical ethics) (Dawson, 2010, 2011).

He has argued that through focusing on different senses of `public' at work in `public health' we can make the best case for exploring the acceptability of public health interventions (Verweij & Dawson, 2007). Further, he argues that citizens, as members of a community and society, are under some obligation to contribute to the common good and, as such, this may justify an obligation to participate in public health programmes. Additionally, the magnitudes of the risks and goods will contribute to the strength of the case for this obligation to participate (Dawson 2004, 2005a, 2005b, 2007).

This final aspect of Dawson's definition of public health ethics, that citizens may be obligated to participate in public health interventions, challenges what he refers to as the special status given to the `liberal' position in medical ethics, whereby individuals are `free' to make their own decisions about the best course of action for themselves. While his work maintains that individual liberty is still an essential value, he argues that there are other values of equal importance that should be considered alongside this. He proposes a reorientation to look at what is shared by human beings as social creatures, arguing that this enables debates about public health to be informed by considerations concerning the common good alongside respect for individual freedom. This suggests a pluralistic system for public health that is able to consider both the individual and the collective (Dawson 2010, 2011).

(2) A Public Health Ethics Framework:

In light of his approach to public health ethics, Dawson has argued that developing frameworks related to decisions to be made about public health interventions aids deliberation by making relevant values explicit (Dawson 2009, 2010, 2011). He argues that this type of ethical framework should ask questions of potential public health interventions as a means of aiding deliberation, rather than providing a checklist of instructions to be ticked off. This method of developing and using a framework provides a sophisticated means of opening up more complex ethical questions — a way of challenging but not necessarily overriding privileged and assumed positions, particularly that of the solitary and unconnected individual and the liberty of that individual. In this way, Dawson argues that good policy framework allows for broader questions, such as about the kind of society we want to live in and the way in which public health interventions may help achieve these ends, to be articulated.

Dawson was at Keele from 2000 to 2011 as Lecturer and Senior Lecturer.

References to the research

The articles in Bioethics (1, 2 & 6) and The Lancet: Infectious Diseases (3) were anonymously peer-reviewed, and the books/chapters (4,5, & 7) went through rigorous peer review processes. 1,2 & a chapter from 4 were submitted to RAE 2008. All can be supplied upon request.

Details of the impact

The principal impact of Dawson's work has been on the development of public health ethics frameworks, which have led to changes to policy and professional behaviour around the implementation of public health ethics programmes. In addition to the impact of his publications, he has also used his research when acting as a consultant on expert advisory panels. The research and public engagement have influenced each other.

(a) World Health Organisation Task Force: Ethical Guidance for Tuberculosis interventions
As a result of his research on bioethics, vaccinations and infectious diseases, Professor Dawson was appointed as one of the twenty-two Expert Members of the World Health Organisation (WHO) Task Force on Addressing Ethical Issues in Tuberculosis Care and Control Programmes, which was formed in 2008. The Task Force was required to complete a comprehensive analysis of the ethical issues in TB and formulate and produce guidance. The resulting document, Guidance on ethics of tuberculosis prevention, care and control [source 1], was published in Dec 2010 with the purpose of providing governments and other stakeholders with guidance on how to implement TB care and control programmes in an ethical way [source 2]. Dawson wrote the first draft of the section on values at the start of the document (a fifth of the total text) and his definition of public health is used centrally in the document to identify the need for co-ordinated action to generate conditions in which all members of the community are protected (p. 6). This document provides the ethical reasoning for the collectively organised (public health) action on TB that the WHO advocate, and adds significant weight to the WHO argument that access to TB care is a global welfare right that governments have a duty to provide. The impact of this document has been substantial in the attention that has been paid to it by the target audience; for example, it is cited by Public Health England as a key document on TB for Health Workers [source 3]; its impact continues as this document is still used today as a basis of training workshops focused on frontline medical staff and national policy makers by WHO's Stop TB campaign all around the world.

(b) A Public Health Ethics Framework: Ontario, Canada
Public Health Ontario is responsible for all aspects of public health activity in Ontario (the most populous province in Canada). Dawson was one of six members of the Conceptual Framework Working Group. The group's first publication was a consultation document An Ethical Framework for Public Health Projects: A Discussion Paper. The document uses Verweij and Dawson's definition of Public Health as a key definition (2011, source 4, p. 3). This was circulated to various public health professionals and academics in the Province. This discussion paper and subsequent feedback was then used to inform the development of a framework in 2012, A Framework for the Ethical Conduct of Public Health Initiatives [source 5], to `guide the ethical conduct of evidence-generating public health initiatives'. This white paper adopts the public health framework approach of Dawson whereby questions are used to examine the issues and to consider the interests of all stakeholders, particularly emphasising the positive obligation to promote equality and reciprocity [source 5]. It cites Dawson and his work throughout, in particular drawing on his research to demonstrate the need to develop a framework specifically for public health ethics (p. 6) and to explain how the framework is necessary for providing guidance to determine when public health interventions may restrict individual autonomy (p. 7). This framework has been useful in guiding Public Health Ontario (PHO) in the development of a new ethics review approach, with the framework being used to guide investigators in the ethical reflection of core principles in the planning and review of evidence-generating public health initiatives, for example in program evaluation, surveillance, quality improvement activities, and public health research. This approach is currently being piloted by Public Health Ontario staff through a suite of ethics support services which include (1) ethics advisory services, (2) ethics education, (3) public health ethics resources and (4) ethics review process and board, and so is used by public health professionals in Ontario on a daily basis [source 6].

(c) British Medical Association: Advice on Hepatitis B vaccination
Dawson's research has influenced debate among medical practitioners about universal vaccination. An article by Dawson in The Lancet (Dawson, 2005) advocates the universal immunisation of children in low-risk countries, such as the UK, as a preventative measure against the dangers posed by this quickly spreading disease based on his wider arguments about public health. This appears as a key citation in the British Medical Association's policy on "Hepatitis vaccination in childhood" [source 7], in support of their call for universal immunisation. When it was first published in 2006 (subsequently updated, in 2010) it received wide media attention [source 8]. Dawson's article is also cited in a paper on childhood vaccinations [source 9] in a practitioner journal for paediatricians and health care professionals. The paper advocates Hep B childhood vaccinations and uses Dawson's article to support this argument.

(d) Médecins Sans Frontières (MSF) Ethics Review Board
Dawson has been a member of Médecins Sans Frontières Ethics Review Board (MSF ERB) since 2009. The ERB reviews all MSF research (used by MSF to improve its clinical practice and advocacy work) and provides guidance on working/practical issues and policies. In 2013 the ERB produced a new document entitled Ethical Guidelines for Research. This document was largely written by Dawson and adopts his approach to frameworks (Dawson 2009) — a series of ordered questions to facilitate deliberation by researchers and other non-experts — about how to produce ethical research. This is now the key document for discussing ethics in all research conducted by or sponsored by MSF [source 10].

Outlined here are specific examples where Dawson has had significant impact on the development of particular approaches to addressing public health ethics. But by establishing public health ethics as a distinct sub-discipline within bioethics (for example, through establishing the key Public Health Ethics Journal and editing collections of papers) Dawson has been instrumental in the construction of public health ethics in itself and therefore has facilitated the impacts of others working in the field. Examples include references to his work in reports on Polio vaccination campaigns in India [Source 11] and being commissioned by the Centers for Disease Control and Prevention (CDC), a US federal agency, to help shape a White paper on the ethics of public health emergencies [source 12].

Sources to corroborate the impact

Source 1: WHO (2010) Guidance on ethics of tuberculosis prevention, care, and control. World Health Organisation, Geneva.

Source 2: WHO webpage: Ethical issues in tuberculosis care and control
http://www.who.int/tb/challenges/mdr/ethics/en/

Source 3: Public Health England Website: TB guidelines and key documents
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Tuberculosis/Guidelines/TBGuid01 Guidelines/

Source 4: Public Health Ontario (2011) An Ethical Framework for Public Health Projects: A Discussion Paper. Public Health Ontario: Toronto

Source 5: Public Health Ontario (2012) A Framework for the Ethical Conduct of Public Health Initiatives. Public Health Ontario: Toronto

Source 6: Corroboration from Public Health Ontario

Source 7: BMA (2010) `Hepatitis B Vaccination in Childhood: A briefing from the Board of Science'

Source 8: The Telegraph, April 12^th, 2009 `Vaccination fears over plan for Hepatitis B jabs for babies': http://www.telegraph.co.uk/health/healthnews/5145192/Vaccination-fears-over-plan-for-Hepatitis-B-jabs-for-babies.html

Source 9: "Should universal hepatitis B vaccination be introduced in the UK?", Archives of Disease in Childhood, (Arch Dis Child. 2006 April; 91(4): 286-289). ACD is a journal for paediatricians and health care professionals. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2065978/

Source 10: Ethics Review Board (2013) Ethical Guidelines for Research. Médecins Sans Frontières.

Source 11: The Hindu Times, June 5^th, 2012 `Ravenshaw varsity students to conduct study on polio vaccination': http://www.thehindu.com/todays-paper/tp-national/tp-otherstates/ravenshaw-varsity-students-to-conduct-study-on-polio-vaccination/article3492242.ece

Source 12: Centers for Disease Control and Prevention (CDC) — US federal agency Ethical Guidance for Public Health Emergency Preparedness and Response: Highlighting Ethics and Values in a Vital Public Health Service published in 2008.