Opening or Closing the Window: Can the “Multiple Streams Framework” for Policy Benefit Bioethics?

The public policy theory of multiple streams formulated by John Kingdon in 1984 applies to problems at a time when they become ripe for solving. By aligning the problem, policy, and political “streams” a window to solving the problem arises. In public health, the analysis was applied to UK health disparities and to obesity in Arkansas.

Streams may matter to bioethics as well. That is, bioethics, while distinct from public health, is not beyond politics. The obesity crisis reflects ethical policy lapses, both corporate and government. In Arkansas, the obesity crisis was personal to some people in positions of power and noted in public health data. The comprehensive legislation came when there were political means to achieve it. Growing awareness of issues, public health awareness campaigns, the support of the Arkansas Speaker of the House, and a national conference with a regional obesity discussion led to the alignment of the problem, policy, and politics.

In the bioethics arena, public policy can support ethical goals. But bioethics goes further than public health which is concerned with largescale data. To bioethicists, the obesity problem, for example, concerns how people treat people with obesity, why (not just that) income is inversely related to obesity, how patients with obesity may be disrespected in the doctor-patient relationship, the personal effect of food unaffordability, and the social determinants of health. The prevailing questions must include not just whether a policy will improve health but whether it is an ethical policy and would achieve the desired goals in an ethical way. (E.g. an authoritarian government could solve it unethically.) There even could be one more stream to be aligned to navigate the ethical territory.

When Exworthy, Blane, and Marmot analyzed health inequalities in the UK, they found a growing body of reports highlighting the problem but a policy and political lapse. The authors looked to encourage the policy and political opening using a “policy windows” approach. Adding in an ethics stream distinct from or within the problem or the policy streams could highlight the ethical problem of failure to enact legislation, making the issue one of a moral lapse rather than just a policy lapse. While righteousness could be viewed negatively, an opening to report why the lapse is an ethical wrong in a personal way could garner added political will.

Th US is currently experiencing an open window in the policy arena. To take advantage may require noting not just the existence of problems but the moral lapse associated with those problems. Bringing people together in moral consensus or looking for overlapping ethical consensus could lead to policy changes.

Exworthy M, Blane D, Marmot M. Tackling health inequalities in the United Kingdom: the progress and pitfalls of policy. Health Serv Res. 2003;38(6 Pt 2):1905-1921. doi:10.1111/j.1475-6773.2003.00208.x

Daniel Béland & Michael Howlett (2016) The Role and Impact of the Multiple-Streams Approach in Comparative Policy Analysis, Journal of Comparative Policy Analysis: Research and Practice, 18:3, 221-227, DOI: 10.1080/13876988.2016.1174410

Brent Molough, PEEL Public Health, “The Use of Policy Frameworks to Understand Public-Health Related Public Policy Processes.” October 2012.

John Kingdon, Agendas, Alternatives and Public Policies, 1984 (Boston: Little, Brown and Company). 

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