Epidemiology and Bioethics: A Plea for Reconnecting with the Public (Ethics in Public Health) (Report‪)‬

Epidemiology and bioethics share a common goal. Both seek to protect the public from harm and in doing so potentially improve the health and well-being of the public. These are not disciplines founded upon theories and methods; instead they are mandated by practicalities. Epidemiology is mandated to understand the causes of illness in populations and thus suggest ways to eliminate or alleviate these causes. Epidemiological methods are not an end in themselves; they are means to an end. Bioethics is similarly mandated by practicalities. Although definitions of the discipline vary considerably, in the main bioethics is mandated to address the social implications and concerns of developments in medical science. The argument taken is that without maintaining an awareness of public duty, both disciplines will find themselves increasingly addressing issues that are largely irrelevant to the public, while those issues that affect the greatest numbers of people and the most disadvantaged populations of the world will be largely ignored. One extended quote will suffice to demonstrate the issue at hand within epidemiology. Neil Pearce (2007) has argued that "Traditional approaches to epidemiology started from the standpoint of populations, which involved messy considerations such as context, culture, history and socioeconomic status, all of which strongly influenced health. 'Modern epidemiology' strips away all of that 'noise' and follows a randomized clinical trial paradigm in which risk factors and disease outcomes are considered in isolation, and the aim of an epidemiologic study is to obtain the same findings that would have been obtained with a randomized controlled trial." (1) How, one might ask, can a discipline engage with the public while it is simultaneously attempting to remove context, culture and history; in other words to remove that which constitutes a population, and more significantly that which is of fundamental importance in understanding the unequal burden of disease in populations? There are parallel issues in bioethics. Whether one agrees fully or not with the characterization bioethics is given, few would not recognize some elements of truth in Larry Churchill's (1999) critique that "bioethical disputes--as measured by the debates in journals and conferences in the United States--often seem to be remote from the values of ordinary people and largely irrelevant to the decisions they encounter in health care. In this sense, philosophical theorizing might be considered harmless entertainment, which if taken too seriously would look ridiculous, as several Monty Python skits have skilfully demonstrated." (2) Churchill's critique appears unduly harsh; although many of these debates appear speculative, they often serve a purpose in revealing hidden inconsistencies and spotting the potentially harmful consequences of some forms of new health technology. However, the underlying critique remains valid; there appears to be little desire to get involved with the ethics of health care as experienced by the public.