Public health should not be a popularity contest: a reply to Gavin Mooney

Proceduralism and its role in economic evaluation and priority setting in health

This paper provides a critical overview of Gavin Mooney's proceduralist approach to economic evaluation and priority setting in health. Proceduralism is the notion that the social value attached to alternative courses of action should be determined not only by outcomes, but also processes. Mooney's brand of proceduralism was unique and couched within a broader critique of 'neo-liberal' economics. It operated on a number of levels. At the micro level of the individual program, he pioneered the notion that 'process utility' could be valued and measured within economic evaluation. At a macro level, he developed a framework in which the social objective of equity was defined by procedural justice in which communitarian values were used as the basis for judging how resources should be allocated across the health system. Finally, he applied the notion of procedural justice to further our understanding of the political economy of resource allocation; highlighting how fairness in decision making processes can overcome the sometimes intractable zero-sum resource allocation problem. In summary, his contributions to this field have set the stage for innovative programs of research to help in developing health policies and programs that are both in alignment with community values and implementable.

[Acceptability of harm reduction interventions: contributions of members of the population to the debate about public health ethics]

OBJECTIVE

To explore convergence and divergence in ethical stances of public health and of members of the population regarding acceptability of harm reduction interventions, in particular needle exchange programs.

METHODS

Forty-nine semi-structured interviews were conducted with French-speaking residents of Quebec City. Content analysis was done to explore the views of the respondents with regard to injection drug users (IDUs) and interventions addressed to them, as well as Quebec policies on harm reduction.

RESULTS

Four main categories of social representations about IDUs have emerged from the discourses of the respondents. IDU were represented as: suffering from a disease (n = 17); victim of a situation that they could not control (n = 14); having chosen to use drugs (n = 12); or delinquent people (n = 6). Those social representations were associated with different ethical stances regarding acceptability of harm reduction interventions. Main divergences between respondents' ethical positions on harm reduction and public health discourses were related to the value of tolerance and its limits.

CONCLUSIONS

The Quebec City population interviewed in this study had a high level of tolerance regarding needle distribution to drug addicts. Applied ethics could be a useful way to understand citizens' interpretation of public health interventions.

Should public health experts listen to the people or tell them what to think and do? Yes and no, more or less

This article refers to Margo Kingston's analysis of Pauline Hanson's doomed election campaign in 1998 (Kingston M. Off the Rails: The Pauline Hanson Trip. Sydney: Allen and Unwin; 1999) for insights that may resolve the Chapman/Mooney debate. Should we listen to Pauline Hanson or tell her and her One Nation colleagues what to think and do? Yes, and no, more or less. If more Australian citizens were given access to the material, social, educational and other privileges that Margo Kingston has enjoyed we wouldn't have a debate.