HARVARD GAZETTE ARCHIVES

Dan Brock is one of several senior scholars in bioethics who've recently joined the faculty. (Staff photos Kris Snibbe/Harvard News Office)

"The principal explanation is that Kerala has high literacy rates, especially among women, and it turns out that this is a major factor in determining the health of a population. When women are educated, they become more independent, they're better able to respond to health literacy efforts, and better able to seek out health care."

As director of the recently launched University-wide Program in Ethics and Health, as well as director of the Medical School's Division of Medical Ethics, Brock is helping to guide bioethics (a field he helped create) in a new direction.

Brock works in conjunction with five prestigious and influential scholars who form the steering committee for the Program in Ethics and Health: Allan Brandt of the Faculty of Arts and Sciences (FAS), Norman Daniels of Harvard School of Public Health (HSPH), Frances Kamm of the Kennedy School of Government (KSG) and FAS, Robert Truog of Harvard Medical School (HMS) and Daniel Wikler, HSPH. In addition to focusing on ethical dilemmas that primarily affect individuals (abortion, reproductive decisions, end-of-life issues), Brock and his colleagues are addressing policy issues that affect the health of entire populations, an area that many predict will become increasingly important over the next few decades.

"Some of the major determinants to health are not access to health care but what are called social determinants, factors like literacy, education, sanitation, transportation, clean water, socioeconomic equality. You've got to pay attention to other things beside the health care system. If you don't take the broader view into account, you close your eyes to most of the things that impact the health of the population."

A trained philosopher and the author of three important books on medical ethics - "From Chance to Choice: Genetics and Justice" (with Allen Buchanan, Norman Daniels, and Daniel Wikler, 2000), "Deciding for Others" (with Allen Buchanan, 1989) and "Life and Death" (1993) - Brock began shifting his interest toward broader health policy issues in the mid-1990s. The change came about partly as the result of his appointment in 1993 to the Clinton Task Force on National Health Care Reform. Although the task force was unsuccessful in bringing about a basic restructuring of the national health care system, Brock found the experience of working with the group an extremely enlightening one, which profoundly influenced the future course of his career.

"It reinforced my wanting to work on issues of broader health policy and population health."

Frances Kamm often works out answers to complex ethical questions through the use of hypothetical situations.

Brock comes to Harvard after many years at Brown University and a stint at the National Institute of Health (NIH). He's one of several senior scholars in the field of bioethics who recently have joined the Harvard faculty and, through their participation in the new University-wide initiative, promise to enhance Harvard's already considerable resources in bioethics, medical ethics, and the ethics of population health.

Can health standards be universal?

One of these scholars is Daniel Wikler, the Mary B. Saltonstall Professor of Population Ethics in the Faculty of Public Health. Wikler earned a Ph.D. in philosophy in 1976 from the University of California, Los Angeles, and served as the first staff ethicist for the World Health Organization (WHO). One of the issues he has struggled with is how best to understand the ethical principle that the health of all people is of equal value. This moral concept is often expressed by insisting that there be no "double standards" in health care, despite the huge disparities existing between and within nations in both wealth and health.

The issue is a troubling one because it calls into question a basic principle of modern health care practice. In fact, it is a principle that is literally carved in stone - and in multiple languages - on the Huntington Avenue façade of the School of Public Health's Kresge Building: "The highest attainable standard of health is one of the fundamental rights of every human being."

It is an assertion few would argue with, and yet, as Wikler points out, health care workers and researchers commonly face situations in which well-intentioned but inadequately thought-out attempts to adhere to this principle lead to undesirable consequences. The treatment of rotavirus, one of the principal causes of diarrhea in children, offers a concrete example of this problem.

In developed countries, most cases of rotavirus are treated successfully, but in developing countries many children die yearly from the disease. Several years ago, researchers developed a vaccine that prevents rotavirus infection, but it had the side effect of causing malformation of the intestine in a small percentage of cases and was consequently pulled from the American market. Health ministers in developing countries followed suit and banned the vaccine on the principle that what constitutes a health risk for a child in a wealthy society is no less a risk for a child in a poor one. But for Wikler, this reasoning does not hold up to analysis.

"It ignores the fact that the risk of administering the vaccine is tiny compared with the risk posed by the rotavirus. Many thousands of children have died since then of a disease that was largely preventable. If the ethical issues had been better analyzed and articulated, there might have been a major health impact."

Wikler has written a paper on the subject, arguing that in order to ensure that every child receive the best possible treatment - the universal standard - it may be necessary to administer different treatments in different societies; i.e., in the United States it may be best to withhold the rotavirus vaccine, but in a developing country it may be best to use it.

The rotavirus case is typical of the perplexing health policy issues that workers in developing countries face every day. Nor are there easy answers, but it is just this sort of difficult terrain that medical ethicists are trained to navigate.

"There's no substitute for thinking hard. You have to tease out the questions and answer them one by one, start from the ground up and build an argument, ask yourself what ground are you standing on? Often what you can do in this work is to challenge people to show that what they think is consistent."

One of Wikler's goals for the Program in Ethics and Health is to train people from related fields in the hard work of thinking through ethical dilemmas.

"We're hoping to add competence in this field to the training of people in other fields. We have accepted responsibility for an ethics track in the Harvard Ph.D. program in health policy. We'll be working with economists, epidemiologists, and management specialists, and we've initiated a postdoctoral program in ethics and health."

More than medicine

Daniels, who shares the Mary B. Saltonstall Professorship with Wikler, earned a Ph.D. in philosophy from Harvard in 1970. He studied with John Rawls, whose 1971 landmark book "A Theory of Justice" argued that just societies are those that work to the advantage of people who are least well-off. Daniels' 1985 book "Just Health Care" is an attempt to fit the basic premises of Rawls' work to the problem of health care.

He is currently writing "Just Health," which began as a revision of the earlier book but is evolving into a discussion of the social factors that affect population health and its distribution.

"One of the central effects of disease and disability," he said, "is to restrict the range of opportunities open to people. So in designing a health care system one should think about a principle of protecting what Rawls calls 'fair equality of opportunity.'"

Like Wikler, Daniels views health as more than just providing adequate medical attention. The social determinants of health may include items that lie well outside traditional health care discussions, things like income, education, and political participation.

"They all have a vast impact on health and the distribution of health within a population."

Daniels has put these ideas into practice by developing a complex system for evaluating health care reform efforts that has been used on a demonstration basis in more than a dozen countries. The benchmarks he has created cover everything from classic public health measures like cleaning up drinking water to less traditional concerns like road improvement, health care efficiency, and provider autonomy. The question he is often asked is whether it is realistic to expect health ministries to undertake such sweeping improvements. His answer is emphatic.

"I think historically the problem with health sector reform is that it has taken on too little. The tendency, especially in developing countries, is to think of health sector reform as just medicine."

Putting emotion aside

Frances M. Kamm, the Littauer Professor of Philosophy and Public Policy at the Kennedy School of Government, is another ethicist who has given much of her attention to questions of health care and is another participant in the initiative on Ethics and Health. The author of "Creation and Abortion" (1992), "Morality, Mortality, Vol. I: Death and Whom to Save from It" (1993), and "Morality, Mortality, Vol. 2: Rights, Duties, and Status" (1996), she, like Brock, Wikler, and Daniels, is an enthusiastic believer in the power of rigorous, systematic thinking to provide answers to the difficult questions faced by physicians, researchers, and policy-makers.

Like many in her field, Kamm often works out answers to complex ethical questions through the use of hypothetical situations. In her book "Creation and Abortion," she asks her readers to consider what responsibility they would have toward an adult who had somehow been forcibly connected to their body and could not be removed without suffering death.

"I'm trying to put to one side the emotional concerns and to think of another context, one that has never occurred but is analogous in some way with the issue at hand. If we work at these questions patiently and rigorously, we'll find the answer, and we'll be able to convince reasonable people that one argument is better than another," she said.

Kamm is convinced that people who have little or no experience with philosophical thinking can understand the sort of analysis that she uses to sort out ethical problems and can be convinced by it if the logic is fundamentally sound. She remembers the first time she presented her hypothetical arguments concerning abortion at a political convention, uncertain of how her audience would respond.

"Many of them came up afterward and said, 'We never thought about it this way before. It really makes you think about the problem in a new way.'"

Although many ethical questions in the biomedical field have become deeply politicized, Kamm believes that the work of ethicists can still have an important impact on public policy as well as on individual clinical decisions.

The future of bioethics

There is every reason to believe that Brock, Wikler, Daniels, Kamm, Truog, and Brandt will soon make Harvard one of the leaders in bioethical research and teaching. New interfaculty working groups are being launched in the following topics: professionalism, setting priorities in global health, ethical concerns in research with human subjects, the implications of global aging, and the impact of genetics on society and population health.

The Program in Ethics and Health will work very closely with another recently established program, the Harvard Initiative for Global Health, headed by Professor of Population Policy and Professor of Social Medicine Christopher Murray. Together, the two programs will focus attention not just on health care, per se, but on other factors that contribute in secondary but powerful ways to the health of populations throughout the world.

Said Brock: "Ethics in the clinical setting is still very important, of course, but we're trying to expand bioethics from its traditional clinical focus to also include a group of issues that arise when you take a bird's-eye view of health and populations. We want to try to raise the quality of work in this field, and we want to train people in this area as well."