Today Our Health and Our Principles are Challenged on Many Fronts Simultaneously, Where Can We Go from Here?

Commentary

I’m writing today to revisit some of the themes I’ve addressed in these pages as potential issues to be wary of in the future, but the future is now. We are experiencing threats of people losing healthcare coverage or access through Federal policy action and potential closing of facilities though other Federal policy action. Clinicians warn of the traps inherent in insurance coverage (refusal to cover procedures, new definitions of “medically necessary” and “pre-existing condition”). Corporate Healthcare leaders warn of fiscal crisis, and Public Officials offer us scenarios incompatible with the reality we experience. At the same time, we see prescription drugs, non-prescription drugs, devices and interventions promising relief and cures advertised, often with little or no evidence. At the same time the Federal Government agencies we have come to count on in these instances have reduced staffing (eliminating many highly qualified professionals and adding political appointees whose strongest qualification is often loyalty to leadership) [1]. The resulting misinformation and disinformation have already resulted in reduction in use rates of life saving vaccines and other counterproductive decision making [2]. My contention I will discuss and explain today is that we need to revisit the basics of principles and incorporate them into our decision making at all levels [3, 4].

This strategy first requires a strong basic understanding of the principles I mention. These are the Principles of Bioethics described by Beauchamp and Childress [5]. Allow me to illuminate these ideas and their potential application today.

Commentary

Autonomy

The respect for individuals exercising a right to informed decision making requires that facts inform those decisions. Repeatedly exposing them to someone’s opinion that it is based on fantasy or falsehood is a violation of the next principle. This principle applies both to individuals and applies to decision making bodies. The prerequisite of full knowledge and understanding of the implications and impacts for the individual(s) and populations potentially impacted is essential. It isn’t possible to apply this principle when the prerequisites are ignored as we’ve seen with DHHS Secretary Kennedy removing all seventeen members of the CDC Advisory Committee on Immunization Practices and replacing them with people with little or no relevant experience and many of whom actively oppose vaccines [6, 7]. No advisory group that isn’t appropriately trained and experienced, and in cases like this familiar with the current science can exercise Autonomy in an ethical fashion, and the policies they develop impair individuals’ ability to exercise Autonomy.

Beneficence

This principle calls on all who participate in the health system and development of health policy to do so intending to “do good” and benefit all with their participation and knowledge. Arbitrary reduction in well-established government agencies with responsibilities for supporting public health violates this goal. The same is true of arbitrary reduction in support for insurance coverage – currently seeing last minute debate in Congress. Other arbitrary funding cuts of public health programs - where long- standing evidence shows evidence of benefit to many people – violate this principle and call to question the motivation of the move, and who benefits. This principle also has required prerequisites. These being an agreed upon goal of benefit to all (not just limited populations), a reliance on science and data to achieve this goal, and recognition of this goodness sometimes requiring investment of resources to evidenced- based interventions to achieve the good. Additionally, in order to meet these principles steps must be assured to avoid misinformation and disinformation [2, 8]. The Administration’s proposal to slash over a third of funding in the current year budget undermines any effort to support beneficence, or the public health. Some of the examples of the health risks included in the proposal from DHHS and defended by the Secretary include significant health risks to everyday Americans. These include: • Food Safety at Risk: Reduction of staffing and resources for routine food safety inspections and medical products’ effectiveness – creating immediate and long-term consequences for the populace. • Children at Risk: Elimination of Head Start programs for early childcare and education, lead poison monitoring in schools, the elimination of oral health that affects children disproportionately and causes multiple lifelong health impacts. • Populations at Risk: CDC’s newly appointed Advisory Committee on Immunization Practices (ACIP) has recommended changes (including to age group, type of vaccine, and/or clinical decision-making process) to seven vaccine usage recommendations in the United States: Meningococcal; RSV for adults; RSV for children; influenza; COVID-19; Measles, Mumps, Rubella and Varicella (MMRV); and Hepatitis B. These recommendations, which have been adopted by the HHS Secretary or Acting CDC Director. The combination of these changes (including particularly those that narrow or limit access), portend significant impacts such as driving down already falling  vaccine coverage rates in the United States. Both short-term and long-term negative impacts are predictable up to and including hospitalization, long-term disability and mortality. • Adolescents, Adults and Seniors at Risk: Elimination of chronic pain division and chronic disease programs to improve health treatments for heart disease, obesity, diabetes, and smoking cessation. • Rural Communities at Risk: Elimination of programs that keep rural hospitals open and clinics staffed, including rural hospital flexibility and at-risk grants, rural doctor residency development programs, and state offices of rural health to ensure healthcare access. • Medical Research and Treatment Innovation at Risk: The proposed cuts will halt progress on current medical research and destroy funding for future disease prevention and treatments. Pandemic preparedness will be damaged, promising new treatments will be delayed or terminated, and ground-breaking medical treatments will go undiscovered. • Pandemic Preparedness at Risk: CDC funding cuts will impair the response to new health threats, including a pandemic, such as a measles outbreak, surging flu rates, or other critical health threats. This is complicated by reduced staffing for detection, laboratory testing capacity, and epidemiology to assess the spread of disease. • Loss of Evidence-Based Care Research: The elimination of the Agency for Healthcare Research and Quality (AHRQ) as a standalone independent agency will halt research that improves care quality, patient safety, and healthcare system efficiency—ending initiatives that help reduce preventable hospitalizations and improve outcomes for vulnerable populations. • In-Progress New Therapies at Risk: Elimination of FDA resources to review (for safety and effective [9, 10].

Non-Maleficence

The companion principle to Beneficence is non- maleficence. More commonly known as the principle to “do no harm,” this calls on all of us to avoid harm and potential harm whenever possible. When the policy itself can be a source of harm it is unethical at its core (see examples above). Regarding the concepts of misinformation and disinformation, this principle causes us to ask further: Is this too high a bar for various media? I contend the answer is no. When established science is clear and accepted by experts as fact, sharing related falsehoods is clearly unethical behavior that predictably causes damage and puts the population at risk. Let’s remember, science isn’t a permanent set of truths, science reflects the facts as they are known today – and continues to investigate other theories. Intentionally stating things that have been tested and established to be untrue is lying – never a principled approach to address population health. This item may be worthy of further discussion for emphasis as ignoring the predictable damage of repeating the content of lies could violate many principles, this one in particular.

Justice

What we often call the “Fairness Principle,” calling on us to focus on the “All” as in “All are Created Equal”. Especially in population health, first and always, be truthful. This foundation supports the other Principles and strategies for public health and individuals making healthcare decisions.

In discussing Autonomy, use of truth and a prohibition of misinformation and disinformation are needed to allow the exercise of this principle. When considering Beneficence, the examples above (not an exhaustive list) call into question whether this principle has been a consideration at all. Non-maleficence (part of the oath all physicians and many other health professions take) call on all in these fields and policymakers who respect these professions to first avoid harm. Again, the examples above call this into question.

This concept of justice and fairness also applies to the policies currently debated by policymakers. Access to healthcare is a necessity to live a safe and full life and be a contributing member of society, policies that are designed to limit that access have been proven repeatedly to be biased and create divisions in society. Policy debates designed to limit access, promote misinformation, create unfairness, or otherwise violate any of these principles often (always?) aim to benefit a limited population at the expense of the full population.

An excellent example of aiming to benefit the entire population, reflecting support for Autonomy, an aim of Beneficence and Non-maleficence and incorporating Justice occurred on January 11, 1944. President Franklin Roosevelt proposed a Second Bill of Rights in his State of the Union Address. This, referred to as the Economic Bill of Rights, builds on the original Bill of Rights in the Constitution. That day President Roosevelt said: “This Republic had its beginning, and grew to its present strength, under the protection of certain inalienable political rights — among them the right of free speech, free press, free worship, trial by jury, freedom from unreasonable searches and seizures. They were our rights to life and liberty [11].

As our nation has grown in size and stature, however — as our industrial economy expanded — these political rights proved inadequate to assure us equality in the pursuit of happiness.

We have come to a clear realization of the fact that true individual freedom cannot exist without economic security and independence. “Necessitous men are not free men.” People who are hungry and out of a job are the stuff of which dictatorships are made.

In our day these economic truths have become accepted as self-evident. We have accepted, so to speak, a second Bill of Rights under which a new basis of security and prosperity can be established for all — regardless of station, race, or creed.

Conclusion

The aim of addressing these all after the close of World War 2 was a laudable goal that we have yet to achieve but offer a glimpse of what a principled approach looks like. I contend that these important concepts, opportunities for all that make this a better world for all, require application of an approach that includes the principles described above from planning, policy development, implementation and including evaluation.

In closing some advice I’ve always tried to follow: Aside from basing your policies and actions on principles, first and always, be truthful.