Christoph Schickhardt

Institute for Medical and Data Ethics, School of Medicine, University of Heidelberg

Background: Public health policy, as the field of government action aimed at protecting public health and preventing disease, has a very specific future-oriented dimension: it deals primarily with risks and must make decisions where both the hoped-for future effects and their undesirable side effects are uncertain. This specific temporal dimension has also proved to be a significant challenge during the COVID-19 pandemic. Existing ethical considerations and approaches to public health do not yet take sufficient account of this particular aspect.

Research question: What does it mean for the key concepts and principles of public health ethics to understand them consistently in the light of the specific temporal dimension of public health as a field of action concerning future risks, against a backdrop of uncertainty?

Methodology: i) The starting point is a systematic review of ethical public health frameworks. From this, key ethical principles are identified and analysed for their specific significance in the future-oriented management of risks under conditions of uncertainty. ii) This analysis also applies key considerations from philosophical risk ethics, which have not yet been systematically taken into account by public health ethics. iii) Drawing on ethical and legal literature on the COVID-19 pandemic, the study demonstrates the significant normative role played by the management of risks in the face of an uncertain future. iv) For the purposes of illustration, the study examines whether and to what extent the central ethical principles, as adapted to the ethics of risk, can be applied to the normative challenges posed by a pandemic.

Results: Conventional formulations of general principles of public health ethics show little awareness of the challenges of collective action with a temporal focus on an uncertain future. Risk-ethical considerations drawn from philosophical ethics can provide relevant contributions, for example, to the question of discounting future uncertain benefits or harms; or to the question of the legitimacy of actions whereby citizens or the state create risks for third parties. Public health ethics must focus more strongly on issues of the fair distribution of risks and the management of future uncertainties.