Risk Communication and the Precautionary Principle

The perception of risks for environment and health deriving from globalization processes and an uncontrolled use of modern technologies is growing everywhere. The greater the capacity of controlling living conditions, the larger is the possibility of misusing this power. In environmental and occupational health research we tend to reduce the complexity of the observed phenomena in order to facilitate conclusions. In social and political sciences complexity is an essential element of the context, which needs to be continuously considered. The Precautionary Principle is a tool for facing complexity and uncertainty in health risk management. This paper is aimed at demonstrating that this is not only a problem of technical risk assessment. Great attention should also be paid to improve risk communication. Communication between the stakeholders (experts, decision makers, political and social leaders, media, groups of interest and people involved) is possibly the best condition to be successful in health risk management. Nevertheless, this process usually runs up against severe obstacles. These are not only caused by existing conflicts of interest. Differences in values, languages, perceptions, resources to have access to information, and to express one's own point of view are other key aspects.     

Dimensions of the Precautionary Principle

This essay attempts to provide an analytical apparatus which may be used for finding an authoritative formulation¹ of the Precautionary Principle. Several formulations of the Precautionary Principle are examined. Four dimensions of the principle are identified: (1) the threat dimension, (2) the uncertainty dimension, (3) the action dimension, and (4) the command dimension. It is argued that the Precautionary Principle can be recast into the following if-clause, containing these four dimensions: “If there is (1) a threat, which is (2) uncertain, then (3) some kind of action (4) is mandatory.” The phrases expressing these dimensions may vary in (a) precision and (b) strength. It is shown that it is the dimension containing the weakest phrase that determines the strength of the entire principle. It is suggested that the four-dimensional if-clause be used as an analytical apparatus in negotiations of the Precautionary Principle.     

Methodologic Implications of the Precautionary Principle: Causal Criteria

Applying the Precautionary Principle to public health requires a re-evaluation of the methods of inference currently used to make claims about disease causation from epidemiologic and other forms of scientific evidence. In current thinking, a well-established, near-certain causal relationship implies highly consistent statistically significant results across many different studies, large relative risk estimates, extensive understanding of biological mechanisms and dose-response relationships, positive prevention trial results, a clear temporal relationship between cause and effect, and other conditions spelled out in terms of the widely-used causal criteria. The Precautionary Principle, however, states that preventive measures are to be taken when cause and effect relationships are not fully established scientifically. What evidentiary conditions, as reflected in the causal criteria, will be certain enough to warrant precautionary preventive action? This paper argues that minimum evidentiary requirements for causation need to be articulated if the Precautionary Principle is to be successfully incorporated into public health practice. Two precautionary changes to criteria-based methods of causal inference are examined: reducing the number of criteria and weakening the rules of inference accompanying the criteria. Such changes point in the direction of identifying minimum evidentiary conditions, but would be premature without better understanding how well current methods of causal inference work.     

Implementing the Precautionary Principle: Rigorous Science and Solid Ethics

The Precautionary Principle came out of European efforts to clean-up and protect marine ecosystems in the 1980s. Since then, several North American activities have elaborated on this approach in U.S. environmental programs. Unfortunately, US organizations and agencies have not developed strategies and guidelines for implementing the Precautionary Principle in either statutory or voluntary environmental programs. Recent interest in this approach from some members of the scientific, non-profit, and regulatory communities highlights the need to understand the history and conceptual basis of the Precautionary Principle. In this paper we address several of these issues. First, we summarize the pertinent US history of the Precautionary Principle. Next, we describe the scientific framework for the principle. Finally, we make the case that this provides unique opportunities for scientists to obtain meaning in their work by fulfilling what has been called the new Social Contract.     

Adjusting Scientific Practices to the Precautionary Principle

In most discussions of the Precautionary Principle, it is implicitly assumed that we are at a point near risk neutrality, so that the principle aims at moving away from risk neutrality in the direction of more risk-averse behavior. In this paper it is argued that actual decision-making in environmental issues is often on the opposite, risk taking, side of risk neutrality. A minimal version of the Precautionary Principle consists in moving from such a position in the direction of risk neutrality. Some methods for achieving this are discussed, such as less consensus-seeking scientific procedures, requirements that scientific committees identify less probable but serious scenarios, interpretative presumptions, and supplementary statistical measures for type II errors.     

The Precautionary Principle,Epidemiology and the Ethics of Delay

Ethics tells us: do good and do no harm and invokes the norms of justice, equity and respect for autonomy in protecting and promoting health and well-being. The Precautionary Principle, a contemporary re-definition of Bradford Hill's case for action, gives us a common sense rule for doing good by preventing harm to public health from delay: when in doubt about the presence of a hazard, there should be no doubt about its prevention or removal. It shifts the burden of proof from showing presence of risk to showing absence of risk, aims to do good by preventing harm, and subsumes the upstream strategies of the DPSEEA (Driving Forces Pressure Stress Exposure Effect Action) model and downstream strategies from molecular epidemiology for detection and prevention of risk. The Precautionary Principle has emerged because of the ethical import of delays in detection of risks to human health and the environment. Ethical principles, the Precautionary Principle, the DPSEEA model and molecular epidemiology all imply re-emphasizing epidemiology's classic rôle for early detection and prevention. Delays in recognizing risks from past exposures and acting on the findings (e.g., cigarette smoking and lung cancer, asbestos, organochlorines and endocrine disruption, radiofrequency, raised travel speeds) were examples of failures that were not only scientific, but ethical, since they resulted in preventable harm to exposed populations. These may delay results from, among other things, external and internal determinants of epidemiologic investigations of hazard and risk, including misuse of tests of statistical significance. Furthermore, applying the Precautionary Principle to ensure justice, equity, and respect for autonomy raises questions concerning the short-term costs of implementation to achieve long-term goals and the principles that guide compensation.     

The Precautionary Principle,Science and Human Health Protection

As technology advances rapidly, so do applications with potential adverse implications on human health. The possible threats include risks that can be substantial, far-reaching and irreversible, and currently available methods of investigation, designed to deal with direct exposure-disease associations, are not always suitable. Growing interest is being paid to health effects that may be the consequence of distal, “upstream” determinants. Considering the complex chain of events that links such determinants with health can be extremely difficult, and exposes severe limitations in science. Thus, there is often a mismatch between what is known and what would be required to inform rational, evidence-based decision making, which is increasingly called for. It has become apparent how production and use of scientific evidence in decision making must be accompanied by precaution, especially in those circumstances, more and more common in recent times, where there is an uncertain possibility that serious health consequences might take place. Several cautionary approaches have been proposed, but the Precautionary Principle (PP) has been the object of especially intense debate in recent years. Developed in the field of environmental health, the PP has been clarified, and has been applied or called for in several instances in public health. Although a unique definition is not available, the principle has been characterised, and criteria for its application have been proposed. However, many questions remain open on general as well as specific issues. In this paper, we address some of the questions that are relevant for the PP to support rational decision making in environment and health and more in general to strengthen its contribution towards human health protection.     

Implications of the Precautionary Principle: Is it a Threat to Science?

Scientific research is of proven value to protecting public health and the environment from current and future problems. We explore the extent to which the Precautionary Principle is a threat to this rôle for science and technology. Not surprisingly for a relatively simple yet still incompletely defined concept, supporters of the Precautionary Principle come from different viewpoints, including a viewpoint that is at least uneasy with the rôle of science, and particularly its use in risk assessment. There are also aspects of the Precautionary Principle that inherently restrict obtaining and using science. The Hazardous Air Pollutant (HAP) provisions in the US Clean Air Act Amendments are an example of the Precautionary Principle, which both shifted the burden of proof so that the onus is now on showing a listed compound is harmless, and required maximum available control technology (MACT) instead of a primarily risk-based approach to pollution control. Since its passage in 1990 there has been a decrease in research funding for studies of HAPs. Other potential problems include that once MACT regulations are established, it may be difficult to develop new technological approaches that will further improve air pollution control; that by treating all regulated HAPs similarly, no distinction is made between those that provide a higher or lower risk; and that there is a perverse incentive to use less well studied agents that are not on the existing list. As acting on the Precautionary Principle inherently imposes significant costs for what is a potentially erroneous action, additional scientific study should be required to determine if the precautionary action was successful. If we are to maximize the value of the Precautionary Principle to public health and the environment, it is crucial that its impact not adversely affect the potent preventive rôle of science and technology.     

Some Legal Implications of the Precautionary Principle: Improving Information-Generation and Legal Protections

In creating a legal agenda in service of the Precautionary Principle, the idea of precaution requires more inventories and better monitoring of the condition of public and workforce health than at present. Rectifying problems of the past to better serve the aims of precaution will require more affirmative pre-market and much more post-market knowledge-generation by those who create and use potentially toxic substances, improved pre-market review of substances, better responses to early warnings, and quicker protective post-market responses to evidence of toxicity. This paper conceptualizes a model pre-market screening law to highlight the need for primary prevention measures and to provide philosophic ideas for improving post-market laws and addressing a large universe of existing substances that have been poorly characterized. Although retrospective personal injury law does not have good mechanisms for precaution, even this can be more protective than it is at present by enhancing causes of action for reasonable fear of disease and medical monitoring, and moving to create new causes of action for failure to develop and disseminate information needed to assess the toxicity of substances.     

The Precautionary Principle and Chemical Regulation in the U.S.

Although the statutory goals for chemical regulation are consistent with the precau tionary principle, the current U.S. regulatory program governing synthetic chemicals generally adopts little precautionary controls for the manufacture of most chemicals. For the vast majority of chemicals in use, current law places the burden of producing scientific evidence on the regulatory agency, which actually may serve to discourage companies from testing the safety of their chemicals, since the results could then be used against them in regulatory proceedings. By contrast, for a small subset of chemicals — new chemicals that belong to suspect categories — regulatory controls are quite precautionary. The result of this schizophrenic approach to chemical regulation is a regulatory system that is characterized by the absence of preventative regulation for most existing chemicals, an inequitable barrier to entry for newer safer chemicals, and a lack of information upon which to understand the safety of most chemicals in the U.S. Informal reforms of the current regulatory program are already underway to provide a more consistent and precautionary approach to chemical regulation, although to fully advance the dual goals of regulatory consistency and precaution in the regulation of chemicals, legislative action is necessary.     

On Being Careful What We Wish for: Some Difficulties with Operationalizing the Precautionary Principle

An important part of the Precautionary Principle is that taking action is justified for protecting public health even when there is some scientific uncertainty. We examine here the two components of this central feature of the precautionary principle, scientific uncertainty and decision making. In order to operationalize the principle we should examine the consequences of its decision rules and how they perform under various conditions. The performance of decision rules in disease screening is measured by the sensitivity and specificity of the rule, but the consequences for the patient are given by the positive and negative predictive values, determined not only by the performance of the rule by the prevalence of the disease in the population. We look at positive and negative predictive value of the Precautionary Principle from the standopoint of the costs to one or other parts of society, show that the usual rule which tends to maximize sensitivity in favor of specificity may have unexpected consequences, and demonstrate that it is sometimes possible to trade sensitivity and specificity off against each other in a way the improves both positive and negative predictive value, or worse, degrades both.We conclude by asking if certain strategies are better for one or the other kinds of uncertainty.     

Asbestos in Developing Countries: Magnitude of Risk and Its Practical Implications

In developing countries, aggressive marketing of chrysotile asbestos continues as a result of restrictions on its use being imposed by the developed countries. In the Asian continent, China and India are emerging as the major users of asbestos. There is enough evidence to link chrysotile with pulmonary fibrosis and lung cancer in humans, even at low levels of exposure, hence the need to apply the Precautionary Principle for phasing out its use globally. Due to poor occupational health and safety systems in developing countries and difficulties in early detection of pulmonary malignancy related to asbestos, the statistics remain sketchy. This is hampering efforts to create pressure on policy makers and to counter the propaganda of the asbestos industry. The International Labour Office believes that more than 100,000 deaths a year occur from asbestos-related disease. In the view of studies published in Europe and Australia, the number of deaths due to such malignancies will peak around the year 2020 and could be anywhere between half a million to a million. That means more than a million deaths will occur in developing countries. At about the same time when asbestos-related deaths start to decrease in developed countries, their number will begin to rise in developing countries. This presents a major challenge to the international scientific community.     

Sharing the Knowledge: Sharing Aggregate Genomic Findings with Research Participants in Developing Countries

Returning research results to participants is recognised as an obligation that researchers should always try to fulfil. But can we ascribe the same obligation to researchers who conduct genomics research producing only aggregated findings? And what about genomics research conducted in developing countries? This paper considers Beskow's et al. argument that aggregated findings should also be returned to research participants. This recommendation is examined in the context of genomics research conducted in developing countries. The risks and benefits of attempting such an exercise are identified, and suggestions on ways to avoid some of the challenges are proposed. I argue that disseminating the findings of genomic research to participating communities should be seen as sharing knowledge rather than returning results. Calling the dissemination of aggregate, population level information returning results can be confusing and misleading as participants might expect to receive individual level information. Talking about sharing knowledge is a more appropriate way of expressing and communicating the outcome of population genomic research. Considering the knowledge produced by genomics research a worthwhile output that should be shared with the participants and approaching the exercise as a ‘sharing of knowledge’, could help mitigate the risks of unrealistic expectations and misunderstanding of findings, whilst promoting trusting and long lasting relationships with the participating communities.     

Evaluating the Usefulness of Compulsory Licensing in Developing Countries: A Comparative Study of Thai and Brazilian Experiences Regarding Access to Aids Treatments

While compulsory licensing (CL) is described in the TRIPS agreement as flexibility to protect public health by improving access to medicines in developing countries, a recent literature contends adversely that CL may harm public health. Therefore, this article intends to evaluate the usefulness of CL in the South through the prism of obligations and goals entrusted to patent holders (the effective and non‐abusive exploitation of patents in order to achieve industrial and health developments) and in light of experiences in Thailand and Brazil regarding access to antiretroviral drugs. In this way, it shows that the obligations assigned to patent holders were better served by the recipients of CL and brought significant health and industrial benefits in the two high middle‐income countries. In particular, CL allowed the scaling‐up of free and universal access to antiretroviral drugs by assuring the financial sustainability of these public health programs endangered by monopolistic practices from patent holders.     

The Precautionary Preference: An American Perspective on the Precautionary Principle

The precautionary principle, a familiar constituent of international and European environmental law, has only very recently entered the vocabulary of domestic environmental policy debates in the United States. The question naturally arises what role such a principle should play in American law. By breaking down statements of the precautionary principle into distinct ele ments, one can more readily find ways in which U.S. law reflects the precau tionary principle. This analysis reveals that American environmental law con tains precautionary elements and goals in many and varied settings, from the management of natural ecosystems, to pollution control standards, to risk assessment methodology. However, the precautionary approach appears in a highly diluted or compromised form. With rare exceptions, U.S. law balances precaution against other considerations, most importantly cost. Therefore, while precautionary elements are firmly entrenched in U.S. environmental law, it is more accurate to say that it reflects a precautionary preference rather than the precautionary principle.     

Comparison of Bayesian-Utilitarian and Maximin Principle Approaches

The Precautionary Principle implies the adoption of a set of rules aimed at avoiding possible future harm associated with suspected, but not ascertained, risk factors. Several philosophical, economical and societal questions are implied by precaution-based public health decision making. The purpose of the present paper is to specify the scope of the principle examining the notion of uncertainty involved, and the implication of different approaches to the decision making process. The Bayesian-utilitarian approach and the approach based on the maximin principle will be considered, and the different meaning of prudence in the two settings will be discussed. In a Bayesian-utilitarian approach the small number of attributable cases will end up in a low average expected value, easily regarded as acceptable in a cost-benefit analysis. In a maximin approach, on the other hand, the issue will be to consider the high etiologic fraction of a rare disease in the highest category of exposure. In the light of the aforementioned cautions in interpretation, the core difference between the two approaches has to do with the choice between averaging knowledge or equitably distributing technological risks.     

Avoiding the Trust Deficit: Public Engagement, Values, the Precautionary Principle and the Future of Nanotechnology

Debates about the regulatory requirements surrounding the introduction of nanotechnology products have, at least in Australia, remained largely within disciplinary boundaries and industry and academic circles. This paper argues for a more interdisciplinary and inclusive upstream debate about the introduction of ethical, regulatory and legal frameworks that may avoid the loss of public trust that has characterised the introduction of many new technologies in the past. Insights from risk-perception theory and research are used to introduce the notion of risk as narrative as a framework for action. This paper suggests three main strategies for moving forward; drawing insights from the “trust gap” experiences of other new technologies; the application of the active form of the precautionary principle; and, the creation of nano-futures that meet both community and industry values through effective public engagement.     

Reinterpreting Responsiveness for Health Systems Research in Low and Middle‐Income Countries

The ethical concept of responsiveness has largely been interpreted in the context of international clinical research. In light of the increasing conduct of externally funded health systems research (HSR) in low‐ and middle‐income countries (LMICs), this article examines how responsiveness might be understood for such research and how it can be applied. It contends that four features (amongst others) set HSR in LMICs apart from international clinical research: a focus on systems; being context‐driven; being policy‐driven; and being closely linked to development objectives. These features support reinterpreting responsiveness for HSR in LMICs as responsiveness to systems needs, where health system performance assessments can be relied upon to identify systems needs, and/or responsiveness to systems priorities, which entails aligning research with HSR priorities set through country‐owned processes involving national and sub‐national policymakers from host countries. Both concepts may be difficult to achieve in practice. Country ownership is not an established fact for many countries and alignment to their priorities may be meaningless without it. It is argued that more work is, therefore, needed to identify strategies for how the responsiveness requirement can be ethically fulfilled for HSR in LMICs under non‐ideal conditions such as where host countries have not set HSR priorities via country‐owned processes. Embeddedness is proposed as one approach that could be the focus of further development.     

The Precautionary Principle in the Information Society

The Precautionary Principle aims to anticipate and minimize potentially serious or irreversible risks under conditions of uncertainty. Thus it preserves the potential for future developments. It has been incorporated into many international treaties and pieces of national legislation for environmental protection and sustainable development. However the Precautionary Principle has not yet been applied systematically to novel Information and Communication Technologies (ICTs) and their potential environmental, social, and health effects. In this article we argue that precaution is necessary in this field and show how the general principle of precaution can be put in concrete terms in the context of the information society. We advocate precautionary measures directed towards pervasive applications of ICT (Pervasive Computing) because of their inestimable potential impacts on society.     

Trichloroethylene in the Environment: Public Health Concerns

The Agency for Toxic Substances and Disease Registry (ATSDR) prepares toxi-cological profiles for hazardous substances found at waste sites and elsewhere in the environment. In 1997 the agency updated its toxicological profile for trichloroethylene and included new and expanded information on the health effects associated with exposures to trichloroethylene. Several endpoints of concern are described in the profile. However, in this paper only results from studies reporting developmental and carcinogenic effects from trichloroethylene exposures in human and experimental animal studies are summarized and evaluated. Based on its assessment of the available studies and limitations in the reported findings, ATSDR has determined there is limited but suggestive evidence that developmental effects may be a concern for some persons exposed to TCE in drinking water. Moreover, developmental effects may be the most sensitive of all non-cancer health effects associated with trichloroethylene exposures. Significant questions remain about the likely mode(s) of action for TCE-induced carcinogenesis in humans and the basis for differences in pharmacokinetics handling of TCE across animal strains and sex. However, on the basis of animal data and the suggestive, yet inconclusive, human data available, ATSDR has determined that cancer should be an effect of concern for people exposed to TCE in the environment. ATSDR agrees that the available literature supports the premise that TCE is “reasonably anticipated to be a human carcinogen” as defined by the U.S. National Toxicology Program.