What’s the Big Deal?
The Ethics of Public-Private Partnerships
related to Food and Health
Jonathan H. Marks
Director, Bioethics Program, Penn State;
Non-Residential Fellow, Edmond J. Safra
Center for Ethics, Harvard
Ohio State University Lecture
October 16, 2013
Acknowledgments
– Edmond J. Safra Center for Ethics, Harvard
– Rock Ethics Institute, Penn State
Thanks to:
– Don Thompson
– Chris Mayes
– Susannah Rose
The Advocate
• "[b]y partnering with USDA, corporations win,
USDA wins, and the American consumer wins.
That's a win-win-win situation!"
– US Secretary of Agriculture Tom Vilsack
U.S. Department of Agriculture, “National Strategic Partner List,“ (2013)
http://www.choosemyplate.gov/partneringprogram/nationalpartners/partner-list.html
The Cynic
“Next time you hear of a big food or beverage company
sponsoring an after-school physical activity program in your
community, you can be sure they’ll say it’s to show ‘our
company’s concern for our kids’ health.’ But the real intent
is to look angelic while making consumers feel good about the
brand and drawing attention away from the unhealthful
nature of the company’s products. ‘Posing for holy cards,’
as one of my colleagues used to put it.”
—Michael Mudd, former Executive Vice President of Global
Corporate Affairs for Kraft Foods
“How to Force Ethics on the Food Industry,” New York Times, March 16, 2013,
http://www.nytimes.com/2013/03/17/opinion/sunday/how-to-force-ethics-onthe-foodindustry.html?pagewanted=all&_r=2&
The Concerned
• subordination of institutional values,
• mission reorientation,
• weakened capacity to promote regulations
and monitor compliance,
• displaced organizational priorities, and selfcensorship.
Buse & Waxman, WHO Bulletin, (2001)
Research-Related Concerns
•
•
•
•
quality of research,
research outcomes,
dissemination of research;
public trust
– in science and
– in research institutions.
Walt, Brugha, and Haines, BMJ (2002)
Public Private Partnerships
“cover a wide variety of ventures involving a
diversity of arrangements, varying with regard
to participants, legal status, governance,
management, policy-setting prerogatives,
contributions and operational roles”
World Health Organization, “Public-Private Partnerships for
Health,” http://www.who.int/trade/glossary/story077/en
Taxonomies of Partnership
(1) direct funding,
(2) contributions in kind (goods and/or services),
(3) dialogue (including information exchange),
(4) joint delivery.
United Nations Standing Committee on Nutrition, “SCN Private Sector Engagement
Policy, Rule 20” March, 2006, revised June 19, 2006, available at “SCN Interaction
with Private Sector,”
www.unsystem.org/scn/Publications/html/private_sector.htm
Taxonomy of Engagement
(1) philanthropic—described as ”peripheral” BUT…;
(2) transactional—”mutual benefit”;
(3) integrative—“mission mesh.”
Phases: (1)  (2)  (3)
James E. Austin, “Strategic Collaboration Between Nonprofits and Business,”
Nonprofit and Voluntary Sector Quarterly 29.suppl.1 (2000): 69-97
Vivica I. Kraak, Paige B. Harrigan, Mark Lawrence, et al., “Balancing the Benefits
and Risks of Public-Private Partnerships to Address the Global Double Burden
of Malnutrition,” Public Health Nutrition 15.3 (2012): 503-17.
Philly / ABA / CHOP
http://www.philly.com/philly/blogs/heardinthehall/118077483.html
For example…
ICS Framework
• widespread or systemic practices
(often legal, and perceived as ethical)
• that undermine the integrity or trustworthiness
of an institution
• and/or trust and confidence in that institution
What kinds of “institution”?
• (1) academic research institutions
• (2) professional associations
• (3) scholarly and professional journals
• (4) patient advocacy organizations
• (5) government funding agencies and regulators
• and…(6) body of research as abstract institution.
Institutions: Attributes and Attitudes
Attributes:
Trustworthiness
Integrity
Attitudes:
Trust
Confidence
an important distinction
• If an institution is not trustworthy and/or lacks
integrity, it would be problematic to take steps
solely to restore trust and confidence
Integrity
• relationship between (a) the mission or
purpose of an institution and (b) its practices
• an institution might be said to lack integrity if
its practices predictably undermine the
pursuit of the very goals in terms of which it
justifies its existence
– c.f. Allen Buchanan and Robert Keohane (2006)
Integrity and Public Health
• Health Halo Hazard (and/or)
• Logo effects (may lead to)
• Erosion of mission and integrity of public actor
Healthy Fast Food?
• The Subway “health halo”
– Leads to belief that 1000 kcal Subway meal contains 21.3% less
calories than same-calorie McDonald’s meal (585 v. 744 kcal)
– Calorie underestimates of familiar items such as sandwiches and
burgers by as much as 35%
– Biasing effects of health claims on calorie estimation are as strong for
consumers “highly involved” in nutrition
– Health claims lead consumers to choose side dishes containing more
calories, enhancing chances of overeating
– When main course positioned as “healthy,” customers choose
beverages, side dishes and desserts containing upto 131% more
calories than when main course is not so positioned
• Chandon & Wansink, J. Consumer Res., 2007
Image: AAMC, The Scientific Basis of Influence and Reciprocity (June 2007);
See also: Dana and Loewenstein, JAMA, 2003, esp. on denial of influence
Integrity (cont.)
• Integrity—harder cases:
– Institution with inherently conflicting mission(s)
– Institution in transition
Conflicting Mission of the USDA?
Strategic plan includes:
“expanding markets for agricultural products”
AND
“improving nutrition and health by providing …
nutrition education and promotion”
“Mission Statement,” United States Department of Agriculture,
http://www.usda.gov/wps/portal/usda/usdahome?navid=MISSION_STATEMENT
Trust and Confidence Issues
Public Trust
Industry & Professional Organizations:
Professional Education (ADA-FNCE 2010)
ADA FNCE 2010 (cont.)
Industry and Professional
Organizations
http://www.hersheys.com/moderationnation/
Industry & Professional Organizations
http://www.aafp.org/online/en/home/publications/news/news-now/inside-aafp/20091006cons-alli-coke.html
Global Health Philanthropy
• “the Bill and Melinda Gates Foundation …
will soon be the largest stockholder of
CocaCola and Kraft in the world”
David Stuckler et al., Global Health Philanthropy and Institutional Relationships:
How Should Conflicts of Interest Be Addressed? PLoS Medicine (2011)
Systemic Effects--Research
•
•
•
•
•
Framing effect
Technological bias
Research design
Interpretation
Dissemination
J.H.Marks, “Limits of Money Blinds,” Edmond J. Safra Center for
Ethics, Money Blinds Conference, Paper Presentation, Nov.
2013
Systemic Effects--Policymaking
•
•
•
•
•
preclusion of policy options (e.g. regulation)
marginalization of stakeholders
discounting of evidence
distorted development and implementation
trust and confidence issues
Mayes, Thompson, Marks (2013) (manuscript on file with authors)
SCN Principles (2006-7)
Eight Principles:
•Relevance of partnership to SCN vision and mandate
•Effectiveness and efficiency as relates to SCN’s goals
•Management of CoI (including exclusion in some cases)
•Independence from vested interests (for credibility)
•Transparency
•Diversity (no preferential treatment to private sector org.)
•Safeguards to insulate policymaking from corporate influence
•Promotion of and respect for human rights
And this Rule:
•No financial or in-kind contributions from food-related PSO
Critical Assessment of 12 Principles
in Rowe et al./ILSI (Nutr. Rev. 2013)
1. Clearly defined and achievable public health goal
2. Clear statement of rules, roles, responsibilities, accountability
3. Objectives tied to partner needs, with clear baseline
4. All members possess “appropriate levels of bargaining power”
5. Minimize CoI by recruiting sufficient partners to mitigate
influence and broaden private-sector perspectives
6. Engage partners who agree on specific research questions
Critical Assessment of 12 Principles
in Rowe et al./ILSI (Nutr. Rev. 2013)
7. Engage partners committed to long-term goals and data
sharing
8. Engage academics and members of civil society
9. Select objective scientific measurements capable of providing
common ground
10. Adopt research questions and methodologies established by
partners with no vested financial interest in them
11. Flexibility and Transparency
12. Third party convener
NOTE: ILSI as PPP, and industry authors of paper.
Ethical Analysis
• Substantive Criteria
• Procedure
• Monitoring and Reassessment
J.H. Marks, “What’s the Big Deal? The Ethics of PPPs…,” Edmond J. Safra
Center Working Paper, No. 11 (May 2013), available at www.ssrn.com
Ethical Analysis
• Problems with “risk-benefit analysis”
• Problems with “model PPP” approach
Alternatives:
• Shift presumption (e.g. against)
• Systemic effects (antitrust analogy)
• Counterbalancing (with uplift)
• Speak Up and Collective Action
marks@psu.edu
Images: Donald B. Thompson
• Activia (FTC):
http://ftc.gov/os/caselist/0823158/videos/exhibitF.swf
• Activia (SNL):
http://www.youtube.com/watch?v=dfK3o_OclgU
Image credit: adweek.com
Nutrition marketing of unhealthy foods
• Recent study of six supermarkets in ND:
– 48% of products with “nutrition marketing” were
high in saturated fat / sodium / sugar content
– 59% of products aim at kids and with “nutrition
marketing” were high in sat.fat/sodium/sugar
Colby et al., J. Nutr. Ed. & Behav., 2010
Impact of Nutrition Marketing
• Mixed evidence of public understanding of health
benefits claimed in relation to food:
– Consumers don’t distinguish health claims approved
by FDA (after review of evidence) from other claims
– Some evidence of “halo effect” (e.g. low cholesterol
means low fat, Andrews et al. 1998)
– Some evidence that consumers may believe claim
reflects government endorsement
• But evidence of impact on consumer behavior is
more challenging
– Leathwood et al., Brit. J. Nutr. 2007
Fast Food Industry
• Spent > $ 4.2 billion in advertising in 2009
– TV ads, age 2-5: 2.8 per day (up 21% since 2003)
– TV ads, age 6-11: 3.5 per day (up 34%)
– TV ads, age 12-17: 4.7 per day (up 39%)
• Ads also target ethnic and minority youth,
often with less healthy items
• Rudd Center, Fast Food Facts Report (2010)
Fast Food Industry (cont.)
• 84% parents report taking child at least once
in past week
• 15% of preschoolers ask to go every day
• Rudd Center, FFF (2010)
Fast Food Industry (cont.)
• Of 3,039 kids meal combos:
– only 12 met nutrition criteria for preschoolers
– only 5 met nutrition criteria for older children
• Ave. restaurant: 15 signs promoting specific
menu items; just 4% promoted healthy items
• Default = french fries or unhealthy side 84% of
the time
• Rudd Center, FFF (2010)
Healthy Fast Food?
• The Subway “health halo”
– Leads to belief that 1000 kcal Subway meal contains 21.3% less
calories than same-calorie McDonald’s meal (585 v. 744 kcal)
– Calorie underestimates of familiar items such as sandwiches and
burgers by as much as 35%
– Biasing effects of health claims on calorie estimation are as strong for
consumers “highly involved” in nutrition
– Health claims lead consumers to choose side dishes containing more
calories, enhancing chances of overeating
– When main course positioned as “healthy,” customers choose
beverages, side dishes and desserts containing upto 131% more
calories than when main course is not so positioned
• Chandon & Wansink, J. Consumer Res., 2007
Problems with Healthy Items
• Consumers erroneously believe that eating
healthy foods in addition to unhealthy foods can
decrease a meal’s calorie count
– BUT not think healthy items have negative calories
• Effect stronger among individuals most
concerned with managing their weight (the
“dieter’s paradox”):
– Burger = 711 kcal, but with salad = 615 kcal!
Psych. (2010)
Chernev, J. Consumer.
Problems with Healthy Options
• Presence of healthy food option:
– (1) vicariously fulfils health-related eating goals;
– (2) drives attention to the least healthy option;
– (3) provides license to indulge.
• “Ironic effect of self-control”: these effects are accentuated
for individuals with (relatively) higher levels of self-control
• C.f. Polivy & Herman’s “what the hell effect”!
et al., J. Consumer Research, 2009
Wilcox
Institutional Corruption
• "Institutional corruption" is the consequence
of an influence within an economy of
influence that illegitimately weakens the
effectiveness of an institution especially by
weakening the public trust of the institution.
(Lawrence Lessig, IC Wiki)
http://wiki.lessig.org/Institutional_Corruption
Institutional Corruption: A Framework
• "Institutional corruption" is the consequence
of an influence within an economy of
influence that illegitimately weakens the
effectiveness of an institution especially by
weakening the public trust of the institution.
(Lawrence Lessig, IC Wiki)
http://wiki.lessig.org/Institutional_Corruption
Institutional Corruption
• "Institutional corruption" is the consequence
of an influence within an economy of
influence that illegitimately weakens the
effectiveness of an institution especially by
weakening the public trust of the institution.
(Lawrence Lessig, IC Wiki)
http://wiki.lessig.org/Institutional_Corruption
Dependence Corruption
• a subset of institutional corruption (as well as
individual corruption)
• e.g. the improper dependence of Congress on
campaign contributors
- L. Lessig, Institutional Corruptions,
EJS Working Paper No. 1 (2013)
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