EHJ January 2005, pages 20-22

Every day EHPs make ethical decisions. As practitioners become increasingly involved in the wider public health agenda, Dr Susan Lammin argues it's time for a proper debate about the ethical implications surrounding environmental health

When it comes to human rights, most environmental health practitioners are well aware of their legal obligations. EHPs who work in the public sector are probably as aware, if not more aware, of the European Convention on Human Rights and the Human Rights Act as any other professional in public service. But they will also be aware that there are situations in which the manner of their actions is incompatible with this legislation. In fact, a lot of the legislation under which local authorities have a duty to act has the potential to breach a person's rights.

For instance, by serving a noise abatement notice, an EHP can impinge on a person's right of respect for their private or family life. Yet, if they fail to intervene to resolve a nuisance, their inaction can inhibit a person's peaceful enjoyment of their property and vice versa. When an EHP seeks and subsequently grants an antisocial behaviour order, this impinges on an individual's right to liberty and may affect their right to freedom of assembly and association, depending on the terms of the order. These are powerful pieces of legislation. The introduction of the cabinet system during the modernisation of local government and the necessary increase in officer delegation has meant that EHPs in some local authorities are now able to wield quite substantial power.

The use of power is an ethical dilemma that extends beyond the interpretation of legislation. In Principles of biomedical ethics, Tom Beauchamp and James Childress present four ethical principles on ethical decision-making - respect for autonomy, non-maleficence, beneficence and justice and veracity.

RESPECT FOR AUTONOMY

Personal autonomy is people's capacity to choose freely and to be able to direct their own lives. In every day life, EHPs regularly seek to control the behaviour or responses of others through persuasion, coercion or the overt use of legislative powers, for example, by badgering a food handler to make more regular and better use of the wash-hand basin or trying to dissuade the smoker from "lighting up" at work. Challenging a person's autonomy to achieve what is perceived to be a wider benefit is a regular feature of an enforcement officer's life.

EHPs also exert more subtle influences, sometimes unintentionally. Exercising reasonable choice - taking decisions on the basis of deliberation - is a cornerstone of personal autonomy. But if a reasonable choice that is based on adequate understanding is to be made, a person needs balanced, unbiased information in an accessible form. If an EHP intentionally fails to provide essential information or if it is provided in written form, in terms couched to confuse or obscure the key facts, then is that person not acting unethically? If the act was deliberate, then there is probably an ethical debate to be had. But what about the unintentional effect of the use of jargon?

As a case officer, the need to remain as objective as possible during an investigation, even when making subjective assessments, is impressed on EHPs at an early stage of practical training. From a legal standpoint, to exhibit bias towards one party in a dispute before the evidence has been assessed may prejudice later action. When viewed from an ethical perspective this absence of bias becomes even more important. If a case is investigated from a skewed perspective, and the investigator failed to present an unbiased account of findings, is the recipient of the information not inhibited in trying to make an informed choice, based on that information?

NON-MALEFICENCE

The notion of remaining unbiased in any dispute where an EHP is invited to investigate, mediate or arbitrate raises another ethical consideration. The concept of non-maleficence is "do no harm". The difficulty is that one act can have two possible effects - one good outcome and one harmful, unintended effect. EHPs faced with a busy reactive caseload are regularly challenged by the need to achieve a balanced outcome. The rule is that the harmful side effect should always be proportionally less than the benefit.

An example of this dilemma arose where a couple with learning difficulties, who were living independently in the community, were the victims of a campaign of abuse from within their own family. As a result of this mistreatment, the couple feared the bully and others, and would not answer the door. Waste materials were thrown into the garden and subsequently built up and regular small arson attacks were carried out on piles of materials in the garden. Inevitably, the environmental health department received a complaint from a neighbour who was concerned about the rats being attracted to the gardens by the waste and the burnt remnants of belongings. The ethical dilemma is clear - does an EHP serve a notice on a victimised, stressed and confused couple when rats are discovered? The notice would resolve the rat problem but what of the harm to the individuals who are intellectually unable to cope with the situation they find themselves in and emotionally in a state of acute anxiety.

BENEFICENCE

When faced with a complex case like this, many EHPs will seek to find a solution to the underlying problem, to make life better for the couple. It is the principle of "doing good" and acting for the benefit of others that drives many in the profession. This urge to improve a situation is the foundation of our profession and is exemplified in the CIEH's motto Amicus humani generis (friend of the human race).

David Seedhouse offers some rules to assist ethical decision-making in Ethics: the heart of health care. He says that one ought not to inflict evil or harm, one ought to prevent evil or harm, one ought to remove evil, and one ought to do or promote good. The provision of rules makes the dilemma seem deceptively simple to resolve. It is not.

Considering that there are occasions when EHPs act in a manner that is incompatible with human rights legislation, denying or interfering with a person's human rights could be seen as inflicting harm. However, beneficence is often interpreted via the principle of proportionality where the risks to the individual are justified by the wider benefits. It is known that beneficence can conflict with autonomy, where a refusal to consent to change can conflict with a professional view that change is in their best interest. This may arise where an employee is compelled to change working practices because they put themselves, or others, at risk of harm.

The notion that the professional is competent to judge what is in a person's best interest better than the individual is essentially paternalistic. In Value of life: an introduction to medical ethics, John Harris defines paternalism as "the belief that it can be right to order the lives of others for their own good, irrespective of their own wishes or judgements". Another difficulty arises in determining a person's best interests for them. It is often difficult to determine in what sphere their needs should be protected or championed and what areas are less important. Does the physical need take precedence over cultural, emotional and social needs? This balancing of cultural and social demands can be particularly challenging if the professional adopting the paternalistic stance is not familiar with the cultural or social norms of the individual.

JUSTICE AND VERACITY

Even where an intervention has been deemed necessary because it is seen to be in the best interests of the individual, or of significant wider benefit, the action must still be seen to be fair. Justice is synonymous with fairness. Writing about medical ethics in the British Medical Journal, Raanan Gillon offers three categories of justice - distributive justice, the fair distribution of scarce resources; rights-based justice, the respect for people's rights; and legal justice, the respect for morally acceptable laws.

The concept of justice may provide ethical dilemmas for those making ethical decisions about service provision and cost effectiveness. Tom Beauchamp and James Childress note that the distribution of resources should be governed by equity and fairness but the inequalities in our society are acknowledged. Inequalities exist in an economic, social and health context. There are also inequalities in the provision of environmental health services across the country in terms of both quality and scope of services. However, some of these inequalities in service are justified - the variations to meet local needs do not necessarily produce inequity in services. Raanan Gillons says that the ethical concept of justice is more than equality. It is fair and proportionate treatment according to need.

The final element of justice is veracity. Truthfulness and openness are essential in building co-operative relationships. Both are essential to an EHP. However, the notion of openness poses some difficulties. Openness is governed by legislative constraints - data protection acts, Freedom of Information Act, Health and safety at Work, 1974 etc. Act. Openness is also constrained by the individual's conflicting right to privacy. It may be that the evolution of strategies to meet the needs of the Freedom of Information Act may provide a useful source of additional guidance about achieving openness in the future. Until then, it will remain a matter of balance. Each case will have to be considered on its merits.

Ethical decision-making is part of an EHP's daily activities at all levels from problem solving for individual cases to developing strategies and determining resource allocation. The principles for making ethical clinical decisions and decisions about cost effectiveness in health care are widely disseminated and debated. Those same ethical principles are integral to our profession but are generally less often discussed. As the profession strives to gain wider recognition within the broadening public health agenda, perhaps is a good time to encourage debate about the ethical implications of our work.

Dr Susan Lammin FCIEH, MIOSH, MIOA is head of environmental health services at Huntingdonshire DC. Tel: 01480 388280, e-mail: susan.lammin@huntsdc.gov.uk

The views expressed in this article are those of the author and do not necessarily reflect those of her employer.