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ETHICS IN MEDICINE   University of Washington School of Medicine
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Public Health Ethics

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Public health practice concerns itself with issues of illness and disease of populations, and as such touches some unique ethical issues. In general, public health practices and policies seek to improve the overall health of the public, a position sometimes at odds with the autonomy of the individual. This conflict may be clinical, as in the case of immunization, or legal, as in the case of mandatory medical reporting and treatment of communicable diseases. Further, public health involved recognizing health and illness in the broader context of social, environmental, political, and economic factors. All health care providers share in public health practice, and have opportunities in their actions to shape public health policy.

When should diseases be reported to Public Health authorities?

Each state has specific statutes that identify specific diseases with public health implications, such as communicable diseases, which require reporting. Beyond this legal requirement lies the question of when it is justified to potentially violate confidentiality to protect the public's health. It is ethically justified to disclose a diagnosis to public health authorities if the risk to the public has the following features:
  • the risk is high in probability
  • the risk is serious in magnitude
  • the risk relates to an identifiable individual or group
For instance, if a food handling restaurant worker with acute hepatitis asks that his diagnosis be held in confidence, the physician should nevertheless disclose this diagnosis to the dining establishment or public health authorities, since the risk to the public is high, serious, and relates to identifiable persons (e.g., patron of the eating establishment).

Can patients refuse to undergo routine preventive health measures?

There are a number of preventive health interventions which provide minimal if any benefit to the individual yet provide substantial collective benefit to the public's health. For example, immunizations provide protection but involve some risk to the individual. However, if a public health program can achieve universal vaccination, the overall public health benefits. If a patient refuses a legally required immunization (e.g., in jurisdictions where immunization is legally mandated), this becomes a legal matter. If not legally mandated, an adequately informed refusal, expressing compelling personal or religious beliefs, may be respected.

Can a physician refuse to follow public health mandates that he opposes?

Most public health law and regulations reflect a public policy process that involved tradeoffs. There is seldom certainty in the final policy recommendations, which are often the result of compromise positions of divergent advocacy groups. As a result, physicians and other health care workers may find their own positions at odds with regulations or health care laws. Professionals have an obligation to exercise judgment and not follow laws that are grossly unjust or immoral. Most situations are not this extreme, however. Thus, the health care professional should find ways other than outright disobedience to try to influence health care policy with which she disagrees. No health care provider should be forced to provide a service he morally opposes, but he should also not obstruct others who support it. The best and most constructive way to affect health policy is to participate actively in the policy making process.

When can a patient be held for medical treatment against her will?

This is a controversial area in law, and the law varies by state. The ethical justification for treatment of a patient against his will is based on balancing of the risk to the public versus respecting the patient's personal freedom. If the magnitude of risk to the public is great, many states allow for involuntary treatment. For example, a patient with active pulmonary tuberculosis that is resistant to multiple anti-tuberculosis medications presents a grave risk to the public if her condition is untreated. This arises in part because of the high infectivity of active pulmonary tuberculosis and the relatively small risk to the patient from oral medications for TB treatment. Other conditions for which non-treatment poses little or no threat to the public, such as untreated acute leukemia, can rarely have involuntary treatment justified.
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Core clerkship material for: General Curriculum

Clarence H. Braddock III, MD, MPH
Project Director, Bioethics Education Project
Faculty, Departments of Medicine and Medical History and Ethics

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Last date modified: April 11, 2008