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t was Daniel Wikler's first day on the job in Geneva in 1999 as the World Health Organization's (WHO) first-ever staff ethicist. the phone rang. The ethics of a who vaccine trial conducted ten years ago were being challenged. what should we do, defend it or apologize? asked the worried official on the other end of the line.

"By four o'clock, I had the answer--defend it," recalls Wikler. Meanwhile he had been calling madly all over the world. "It turned out," he adds, "there were people all over the building confronting ethical dilemmas, and they were aware of it. When they heard that there was a professional ethicist on staff--although they didn't quite know what that was!--well, the phone was constantly ringing."

The call for thoughtful analysis of ethical issues has never been greater in public health, especially for international problems. Creative public health approaches like cost-effectiveness research and decision analysis fall like glancing blows around these elusive subjects, nearing but never quite hitting the mark.

The Harvard School of Public Health has responded by appointing Wikler and Norman Daniels to professorships in the Department of Population and International Health. Before coming to the School last fall, Wikler was a professor in the Program in Medical Ethics and the Department of Philosophy at the University of Wisconsin. Daniels was formerly chair of Tufts University's Philosophy Department and also professor of medical ethics at its medical school. Both have national reputations. Working with colleagues at Harvard Medical School and the Kennedy School of Government, they're putting a new brand of macro-level ethics on the map. "Heads are turning a bit--Harvard is way out in front," boasts Wikler.

Wikler and Daniels are roughly the same age (Wikler is 57; Daniels, 61), got involved in bioethics at about the same time, and now have offices just a few feet apart on the 11th floor of the School's Building 1. Along with two others, they are co-authors of From Chance to Choice: Genes and Justice, a book published in 2000. But despite all these intersections, their conversational styles and scholarship are quite different.

Wikler is voluble and Socratic, mischievously rattling your wobbly assumptions and posing hypothetical problems with no easy solutions. His writings are as dense and difficult as the next academic philosopher's, but he also adds some flair as evidenced by titles like "Who Should Be Blamed for Being Sick?" and "Can We Learn from Eugenics?" His curiosity seems restless; his interests, eclectic.

Daniels doesn't put his naive questioner on the spot; instead, he focuses on laying out a few ideas and keeping digressions to minimum. Like Wikler, Daniels has written on an amazingly wide range of subjects, but fairness and justice are a strong, recurring theme. Daniels talks in abstractions--he's a philosopher, after all--but can be refreshingly blunt. Asked if he thought the American health care system was more or less just than it used to be, he shot back: "Less--and harder to reform."

Public health was not on their minds when Wikler and Daniels started their careers. Wikler studied the philosophy of language. The first paper on Daniels's 11-page c.v. is about the discovery of non-Euclidean geometry. Their careers veered into bioethics in the 1970s for different reasons.

In Wilker's telling, bioethics was brimming with opportunities just too tempting for a young philosopher fresh out of graduate school. Medical technologies like renal dialysis were putting life-and-death decisions into the hands of doctors and hospitals. The horrors of Nazi medical experiments and the advent of the randomized clinical trial stirred up swarms of questions about the ethics of human experimentation and the rights of patients.

So social scientists, lawyers, and philosophers raced into the field as if it were an "Oklahoma land rush," says Wikler, he among them. "There were all these problems out there and there was hardly anything written about any of them. That meant if you took up a problem, you could probably write the world's best article on it," he laughs. Wikler ranged all over this uncharted territory, covering everything from limits of behavior modification to fairness of organ recipient selection to definitions of brain death.

Daniels rode a different wave. In 1971, John Rawls published his landmark book, A Theory of Justice. A Harvard political philosopher, Rawls offered an alternative to the utilitarianism principle of the greatest good for the greatest number. Of course it's miles more complex, but in a nutshell, he proposes that just societies and systems are those that work to the advantage of people who are least well-off. Daniels was captivated by Rawls's ideas and wanted to test them. Health care was a petri dish. But Daniels has also thought about how health care factors into making a just society. "One of the central effects of disease and disability is to restrict the range of opportunities open to people," he says, "so in designing a just health care system one should think about a principle of protecting what Rawls calls 'fair equality of opportunity.'"

Daniels has been pulled into public health partly because he started thinking more broadly about health, not just health care. And once health is on the agenda, the plate gets very full. "One has to worry about the broad structures of society and the distribution of what economists and others call goods: income, education, political participation," he notes. "They all have a vast impact on health and the distribution of health within a population."

Daniels has also turned his attention to the processes by which health policy decisions are made. In his view, if there is a difficult decision about what priorities to set or programs to fund, an evenhanded and open process for making those decisions helps bring about a fair result, even if the principles defining that fair result are hazy: "At the very least, you need an account of a fair process to make these decisions. We don't have distributive principles fine grained enough to resolve the difficult cases."

He has put his ideas into practice by developing benchmarks for health care sector reform. With a grant from the Rockefeller Foundation, Daniels has created a complex matrix for rating reform efforts that has been used on a demonstration-project basis in more than a dozen countries. The benchmarks cover everything from classic public health measures like cleaning up drinking water to less traditional concerns like road improvement, health care efficiency, and provider autonomy. Can health ministries be expected to accomplish so much? "I think historically the problem with health sector reform is that it has taken on too little," says Daniels. "The tendency, especially in developing countries, is to think of health sector reform as just medicine."
Wikler says the seeds of his evolution into a public health-oriented bioethicist were planted long ago. "I had always had the feeling that the really important questions were on a large scale," he says. "As a bioethicist you think about the choices clinicians must make and the moral dilemmas in those choices. But what determined the available choices?"

Wikler’s budding interest flowered several years ago when he was a visiting fellow at Harvard and encountered Christopher Murray, a professor of international health economics at the School. Murray was in the midst of his monumental Global Burden of Disease project, an elaborate effort to tally the effects of illnesses according to disability-adjusted life-years, or DALYs. The project raised all sorts of questions about how to value people and years of life depending on age and other circumstances. Wikler says the ethical and philosophical dimensions to those questions "really stimulated my thinking"--and changed his career. Now, by way of Geneva, he has landed in Boston and at the School.

Wikler continues to work on several projects for the WHO, as well as fulfill typical professorial obligations: advising students, arranging seminars, and participating in panel discussions. He has high hopes for raising the profile of the ethics track in the doctoral program in health policy, a program co-sponsored by the School and several other graduate schools at Harvard.

The ethics of conducting research trials in developing countries, AIDS treatment versus prevention in Africa, tests of cheaper but less medically effective therapies--Wikler has found himself in another bioethics Oklahoma land rush. This time, though, the world is the stage and the scarce resources for enormous problems the central issue. "When you direct your attention toward the developing world, the stakes are so much higher," he says. "The questions about health care priorities become very stark. The decisions you make have literally life-or- death consequences for millions."

Daniels and Wikler are at the School to help the public health community figure out how to make those decisions ethically.

Peter Wehrwein

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