Justice in the Humanitarian Context – Maxwell Smith

msmithMaxwell J. Smith, PhD, MSc

Banting Postdoctoral Fellow, Institute for Health and Social Policy, McGill University

During the 2009-2010 H1N1 influenza pandemic I began working as a research coordinator with the ‘Canadian Program of Research on Ethics in a Pandemic’ (CanPREP).  Hosted at the University of Toronto’s Joint Centre for Bioethics, this program of research involved engaging the Canadian public on ethical issues in pandemic preparedness and response (e.g., the use of restrictive measures like quarantine;1 physicians’ duty to care;2 setting priorities for scarce resources;3 and issues pertaining to global governance4).  What became apparent to me when examining the ethics discourses in pandemic planning and response was that a common and unsubstantiated assumption exists; namely, that the ethics of global public health emergency preparedness and response is perceived as being distinct from the way we think about ethics in what might be considered ‘quotidian’ public health.  For example, Kirkwood suggests that “there must be an ‘escalator clause’ in the utilitarian aspect [of resource allocation] that suggests that in the event of an extensive threat to the existence of a population, the force of this utilitarian aspect becomes the primary consideration in proportion to the threat…the greater the threat, the greater the moral force of utilitarianism in making public health decisions”.5  As another example, Veatch asks whether, in public health emergency preparedness and response, we should “retreat to the utilitarian ethic, making an exception to the ethic of justice that generally prevails in American ethics”.6  Do we tend to be more utilitarian in the way we think about preparing for and responding to public health emergencies as compared to the way we make public health decisions in non-emergency contexts?

This question motivated me to focus my doctoral research on examining the extent to which the perspectives of Canadian public health policy-makers involved in public health emergency preparedness and response are similar or different than those involved in other areas of public health, like chronic disease prevention, specifically in regards to how social justice is conceptualized and negotiated in their work.  Using qualitative interview methods, I found that the perspectives of my study’s participants appeared to be influenced by the perceived goals and contextual features that belong to the programmatic area of public health in which they practiced.  For instance, policy-makers involved in public health emergency preparedness and response described this area’s principal aims as saving the most lives and producing the ‘greatest good’.  Justice-based considerations, interpreted almost entirely in terms of equity, were perceived as being external, or even as being impediments, to these consequentialist, if not utilitarian, aims.  Policy-makers involved in chronic disease prevention, on the other hand, described this area’s central aims in terms of equity and justice; its purpose involves understanding and targeting the unique needs of different populations in order to produce equitable outcomes.  On my interpretation, my study’s findings indicate that the perceived role of social justice considerations in public health emergency preparedness and response may be distinct from how their perceived role in chronic disease prevention; where justice-based considerations are perceived to be part and parcel of the aims of chronic disease prevention, they are perceived as external to, if not constraints upon, the ‘prior’ aim of public health emergency preparedness and response, which is to minimize morbidity and mortality for the greatest number.  The findings of this study have led me to consider whether the way we think about justice in the humanitarian context might be distinct from how we think about justice in public health and global health more generally, and if so, whether this is ethically justifiable.

  1. Smith MJ, Bensimon CM, Perez D, Sahni S, Upshur REG. (2012). Restrictive Measures in an Influenza Pandemic: A Qualitative Study of Public Perspectives. Canadian Journal of Public Health, 103(5): 348-352.
  2. Bensimon CM, Smith MJ, Pisartchik D, Sahni S, Upshur REG. (2012). The Duty to Care in an Influenza Pandemic: A Qualitative Study of Canadian Public Perspectives. Social Science & Medicine, 75(12): 2425-2430.
  3. Silva DS, Gibson JL, Robertson A, Bensimon C, Sahni S, Maunula L, Smith MJ. (2012). Priority Setting of ICU Resources in an Influenza Pandemic: A Qualitative Study of the Canadian Public’s Perspectives. BMC Public Health, 12: 241-252.
  4. Thompson A, Smith MJ, Bensimon CM, McDougall C, Perez DF. (2015). “With Human Health it’s a Global Thing”: Canadian Perspectives on Ethics in the Global Governance of an Influenza Pandemic. Journal of Bioethical Inquiry, 12(1): 115-127.
  5. Kirkwood, K. (2010). In the Name of the Greater Good? Emerging Health Threats Journal, 2(E12), 1-3.
  6. Veatch, R. (2005). Disaster Preparedness and Triage: Justice and the Common Good. The Mount Sinai Journal of Medicine, 72(4), 236-241.

Max Smith is a Banting Postdoctoral Fellow at the Institute for Health and Social Policy at McGill University.