Erika Blacksher, PhD
This article provides a brief overview of various definitions and activities of public health, normative concepts and principles integral to public health, and an introduction to several substantive ethical questions and tensions central to public health ethics. The core of public health ethics concerns the moral justification of policies, programs, and the law to protect and promote public health. Because public health encompasses broad social programs and public policies, such as the provision of clean fluoridated water and bans on public smoking, questions regarding the justification of paternalistic interventions, fair distribution of health, and responsibility for health are prominent. Discrete patient care interventions (e.g., vaccinations) also contribute to public health, and difficult ethical questions can arise for health care practitioners. This article will provide some general guidance for health care providers. A list of references and other resources for public health can be found at the end of this article.
What is public health?
There is no settled account or definition of public health. It has been defined numerous ways, reflecting the diverse contexts, activities, and interventions of public health. A sampling of definitions, from general to more specific, include:
- What we, as a society, do collectively to assure the conditions in which people can be healthy (Institute of Medicine 1988).
- The science and art of preventing disease, prolonging life and promoting health through organized efforts of society (Faculty of Public Health of the Royal Colleges of the United Kingdom, as cited in Nuffield Bioethics Council Report 2007, p. 6).
- A movement dedicated to the equitable improvement of health and wellbeing of communities with their full participation. (World Federation of Public Health Associations as cited in Nuffield Bioethics Council Report 2007, p. 6).
- Public health is the science of protecting and improving the health of communities through education, promotion of healthy lifestyles, and research for disease and injury prevention (Association of Schools of Public Health USA).
- The key functions of public health agencies are assessing community health needs and marshalling the resources for responding to them, developing health policy in response to specific community and national health needs, and assuring that conditions contribute to good health, including high quality medical services, safe water supplies, good nutrition, unpolluted atmospheres and environments that offer opportunities for exercise and recreation are available to individuals (World Medical Association 1995).
- [T]he promotion of health and the prevention of disease and disability; the collection and use of epidemiology data, population surveillance, and other forms of empirical quantitative assessment; a recognition of the multidimensional nature of the determinants of health; and a focus on the complex interactions of many factors-biological, behavioral, social and environmental-in developing effective interventions (Childress et al. 2002).
What are social determinants of health?
As these accounts suggest, public health is distinct from medicine in several ways. It is oriented toward the health of populations or groups rather than individuals; the prevention, rather than the treatment, of disease; the elimination of systematic inequalities in population health associated with social class, race/ethnicity, gender, and other markers of disadvantage; and the use of state power and collective resources to accomplish these ends. To pursue these goals, public health must address a broad array of social conditions that extend beyond medical services. The “social determinants of health”-sometimes simply referred to as the conditions in which people grow up, live, work, and play (Commission on the Social Determinants of Health 2008)-include the built and physical environments (e.g., sidewalks, highway safety, food access, water and air quality); conditions of housing, schools, neighborhoods, and the workplace; and broader social, economic, and cultural conditions related to education and employment, income and wealth, racism and sexism, and social support and security (Woolf, Braveman 2011; Jones et al. 2009).
Since its inception, public health has recognized social conditions as basic causes of illness and disease. Upon investigating and reporting on the causes of typhus in 1848, public health pioneer Rudolf Virchow linked famine and poverty with the oppression of Polish peasants and argued that the “elimination of social inequality was the only way to prevent typhus epidemics in the future” (Mackenbach 2009). The late twentieth century has witnessed renewed interest in social determinants as root causes of significant and widening disparities in health-both within and between countries (Commission on the Social Determinants of Health, 2008). In the United States, disparities in life expectancy have worsened for men and women since 1980 (Marmot, Bell 2009), and examples of such disparities are often dramatic. For example, the gap in left expectancy between men in Washington D.C. and in suburban Maryland is 17 years (Marmot, Bell 2009).
Such challenges in combination with the emergence and reemergence of infectious diseases in the late twentieth century (Armstrong et al. 1999) raise many complex ethical questions for international organizations, governments, communities, and individuals. While early ethical commentary focused on cases such as health promotion and HIV/AIDS (Wikler 1978; Pellegrino 1981; Bayer and Moreno 1986; Bayer 1993, 1989), systematic analyses of the ethical foundations and frameworks of public health are much more recent. A journal dedicated to the topic-Public Health Ethics-was not established until 2008.
What is Public Health Ethics?
As with the concept of public health, there is no settled account of the moral concepts and methods of public health ethics. Systematic efforts to articulate ethical principles and frameworks to guide ethical inquiry in public health (Kass 2001; Childress et al 2002; Roberts, Reich 2002; Upshur 2002; Powers, Faden 2006;The Nuffield Bioethics Council 2007; Daniels 2008; Arras, Fenton 2009; Bernheim et al. 2013) identify a number of general moral considerations that include:
- Producing benefits, often but not exclusively health benefits, and often interpreted in health policy as a utilitarian commitment to maximizing aggregate health benefits
- Preventing harms, often health harms, such as preventable morbidity and premature death
- Distributing health benefits fairly, or distributive justice (fair distribution of social goods)
- Procedural justice (fair process), participation, and transparency
- Respecting individual autonomy and liberty of action
- Respecting and fulfilling universal human rights
- Respecting privacy and confidentiality
- Protecting non-dominant subgroups from marginalization and stigmatization
- Building and maintaining trust
Much work needs to be done to translate these general ethical considerations or some subset of them into guiding principles and frameworks for public health policy and practice. Such work entails defining them, determining their scope, specifying criteria for resolving conflicts among them, and so on. Such efforts have produced frameworks of unranked principles (e.g., Nuffield Bioethics Council 2007), theories of social justice (Powers, Faden 2006), among other more practical approaches (e.g., Kass 2001). Such frameworks have counterparts in medical ethics, whose methods reflect a similar diversity (See Bioethics Tools).
How does public health balance the interests of individuals with the interests of the broader public?
Public health activities routinely bring some of these moral considerations into conflict. One major area of discourse and debate concerns the power of public health as an agent of the state to restrict individual choice in efforts to prevent disease and promote health. Many public health activities try to influence individual actions, though they may do so in more or less restrictive ways. Public health policy may eliminate choice altogether through, for example, compulsory quarantine of patients with infectious disease; restrict choice by, for example, banning smoking in public places or fluoridating public water supplies; guide choice through disincentives (e.g., taxes on health-harming goods, such as sugary beverages) and incentives (e.g., tax breaks on health-promoting goods); or inform choice through, for example, food labeling or media campaigns (Nuffield Bioethics Council, see chapter 3).
The analysis of which of these actions are or are not ethically and politically justifiable is often informed by theharm principle, originally articulated by John Stuart Mill in his essay On Liberty. Mill argues “the only purpose for which power can be rightfully exercised over any member of a civilized community against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant” (Mill 1989). Mill qualifies the principle in several ways, for example, making exceptions for children and those cared for by others. But, in general the principle justifies state interference with individual liberty only when individual actions pose serious harm to others. The principle thus presupposes that behavior affecting only the self (“self-regarding behavior”) can be clearly distinguished from that affecting others (“other-regarding behavior”), which may be difficult in a public health context.
Take, for example, the obesity epidemic in the United States, which has the highest rate among Organisation for Economic Cooperation and Development countries (OECD 2012). It has been argued that individual choices that contribute to overweight and obesity constitute an economic harm to others who share in the costs of the chooser’s health care (Pearson, Lieber 2009). Or, consider the dietary choices of an adult who is also a parent of small children. Parents’ meal planning, purchase of groceries, cooking, and direct feeding of a very young child has other-regarding, sometimes deleterious, consequences for children (Blacksher 2008). Such examples suggest that apparently self-regarding choices related to diet might be other-regarding in significant respects. Nonetheless, the distinction between self- and other-regarding behavior has been invoked persuasively in clear cases, for example, to justify the quarantine of individuals with infectious disease that can easily be transmitted or bans on smoking in public spaces to protect others from the harmful effects of second-hand smoke.
What is paternalism and who is responsible for health?
Cases where harm to others is absent or less easily established stir much more debate because they raise the specter of paternalism. Paternalism occurs when the state or an individual interferes with the preferences of a person for her own benefit (e.g., to promote her health) (Childress et al. 2002). Indeed, public health action often seeks to influence human behavior that arguably does no harm to others. Because chronic diseases now account for the majority of deaths, and personal behaviors make a nontrivial contribution to their onset and progression (McGinnis et al. 2002), much public health research and action seeks to change behaviors whose ill effects are felt primarily by those who engage in them. The least controversial tactics for promoting behavior change are educational in nature-providing people with information, whether it be the calorie content of foods, the health effects of certain behaviors, and so on. Educational campaigns are not coercive, as individuals can choose to heed them or not, and they can be argued to support more informed and thus autonomous citizens. Even Mill would likely have endorsed (non-controversial) public education campaigns for this reason (Nuffield Bioethics Council 2007).
Educational strategies, however, often fail to produce behavior change, particularly among socially disadvantaged groups. Take obesity, which disproportionately affects minority and low socioeconomic groups. Education initiatives are most effective for individuals who have the time, interest, motivation, and resources to act on the information and opportunities made available. People who work long hours or double shifts, or who lack access to affordable gyms or safe spaces to walk or exercise, for example, may not have the time, energy, or financial resources to change habits that are embedded in ways of life. Thus, strategies based on education, information, and individual choice can reproduce or even exacerbate health disparities between more and less advantaged groups (Link, Phelan 1995; Link 2008).
To address this challenge, social and material conditions may be remade to support health and healthy choices. In the case of obesity, such measures might include regulating food production (e.g., government choices about which foods to subsidize, banning excess sodium in processed foods), prohibiting the sale of soda and other sugary beverages in schools, and planning communities that will promote walking, recreation, and otherwise positive social connections. This structural approach to public health is, however, often criticized in political contexts such as the United States, where personal responsibility (for health and other goods) and individualism are highly valued. Debate over responsibility for health is not new (Reiser 1985) but it has intensified in the last few decades. One prominent way this debate has played out in U.S. health policy is the increased use of incentives and disincentives to promote the adoption of health-enhancing behaviors in both the private and public sectors. Private employers and state governments have ramped up their wellness programs, offering employees a variety of goods to participate in health screenings, on-site exercise programs, among other activities. While most programs use rewards in some form, the use of penalties is also on the upswing. A high-profile and much criticized example is West Virginia’s Medicaid program, which now requires beneficiaries to sign a personal responsibility agreement in order to receive an “enhanced” package of services (Blacksher 2008).
Critics oppose such programs on numerous grounds. One common refrain is that penalties ‘blame the victim’. Responsibility lies not with these individuals, critics charge, but rather with social institutions and society at large. This claim of social responsibility for health is a critical plank in a larger argument that health (and/or the social determinants thereof) should be subject to considerations of social justice. Agents of public health often claim that health inequalities associated with social class, race, and ethnicity constitute a social injustice because they are caused, at least in part, by socially controllable factors. As Wikler points out, “The locus of blame is key, for if blame is placed on the individual, social structure is exculpated, and the resulting suffering and premature death will not be counted as a social injustice” (Wikler 2006).
What constitutes a fair distribution of health?
Systematic analyses of social justice and health equity are relatively recent (Marchand et al. 1998; Powers, Faden 2006; Asada 2007; Daniels 2008). Such analyses have taken up a number of basic questions, including: Are social inequalities in health unjust? Which inequalities are most urgent? What constitutes a fair distribution of health? A fundamental question concerns the place of social justice as an ethical construct in public health. Is social justice the moral foundation of public health? This view has its defenders (Powers, Faden 2006; Robertson 1998); however, it has not been a standard view. Rather, it is widely assumed that public health and health policy should aim to produce the most health benefits, or aggregate health, in a population (Brock 2000). Similarly, it has been suggested that maximizing benefits and removing harms “provide a prima facie warrant for many activities in pursuit of the goal of public health” (Childress et al. 2002). This utilitarian goal, which aims to maximize aggregate health, is distinct from the distributive goal to produce a fair distribution of health. Although public health activities and health policies may produce more health and reduce health inequalities, health initiatives very often reproduce or exacerbate disparities because, as already noted, better off people tend to benefit sooner and disproportionately from many health promotion interventions (Mechanic 2002; Frohlich 2008).
One common strategy to address this problem is implementing interventions that target vulnerable subgroups. Such targeting may take a variety of forms, such as focused media campaigns, cash stipends, and social and health care services. But targeting also carries an ethical risk-the further marginalization and stigmatization of minority and socio-economically marginalized groups. As commentators have noted, the pursuit of social justice entails not only distributive goals, such as reducing health disparities, but also recognition goals (Fraser 2003, Young 1990, Anderson 1999). This demand of justice has been variously described but generally refers to a form of basic respect for persons that, at the very least, protects non-dominant groups from discrimination and marginalization based on group membership, such as race, ethnicity, gender, sexual orientation, nationality, social class, and so on. Racism and sexism are paradigmatic examples of transgression of basic respect in this sense. Recognition may be further elaborated to include the idea that all persons have an equal opportunity to participate as peers in public life and to have a voice in important public issues, particularly those that directly affect them (Fraser 2003, Anderson 1999).
What is participation in health?
Recognition in this sense lends ethical support to a core value of public health-the notion of participation in health. Participation has long been a basic principle of public health practice and an essential component of health equity (Commission on the Social Determinants of Health 2008). Participation in health is variously defined but generally the idea refers to a collaborative process that equitably engages community members, organizational representatives, researchers, among others in knowledge creation and social change (Rifkin 1986; Robertson, Minkler 1994; Wallerstein, Bernstein 1994; Israel et al. 1998). Participatory processes are defended on grounds that the research and action that result will be more effective, fulfill an obligation of procedural justice, and produce more equitable outcomes (Wallerstein, Duran 2010; Dankwa-Mullen et al. 2010; Wallerstein 2006; Daniels, Sabin 1998). They may also protect non-dominant communities from health interventions that further marginalize and stigmatize them (Blacksher 2012) and may go some distance in cultivating trust between research institutions and community partners (Yarborough et al. 2012).
Ethical Questions for Individual Practitioners
When should communicable 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. If you are not sure whether reporting is required or advised, contact your local public health authority for guidance. Beyond this legal requirement lies the ethical 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 probability of risk is high
- the magnitude of risk is serious
- the risk relates to an identifiable individual or group
Case 1 below discusses this question in the context of a patient with sexually transmitted disease.
Can medical treatment ever be provided against a patient’s 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 the risk to the public versus respecting the patient's personal freedom (see discussion of the harm principle above). If the magnitude of risk to the public is great, many states allow for involuntary treatment. Health care providers have obligations, however, to use the least restrictive means to achieve the therapeutic goal. An involuntary hospital stay is the most restrictive, necessary only when there is high risk of infecting others as well as evidence of non-adherence to outpatient treatment. A less restrictive approach utilizes directly observed therapy, in which a designated provider or case worker observes the patient taking his medications at home or in another outpatient setting. Case 2 below discusses this question in the context of a patient with active multi-drug resistant pulmonary tuberculosis.
Can patients refuse to undergo routine preventive health measures?
Sometimes there are preventive health interventions that provide minimal or no benefit to the individual, yet provide substantial collective benefit to the public's health. Immunization is a good example. If most of the people in a region are vaccinated, those who are not vaccinated are also protected from the contagious disease because the likelihood of an outbreak is low. This is known as herd or community immunity. Hence vaccination protects others, especially infants and those with compromised immunity (due to chemotherapy, for example). If a patient refuses a legally required immunization (e.g., in jurisdictions where immunization is legally mandated), this becomes a legal matter. This issue arises more often as an ethical (not necessarily a legal) matter, however. An effective response is to maintain a therapeutic alliance with a child’s parent in order to address fears and concerns about vaccination and to gently persuade them of the importance and safety of vaccination (Opel 2012). If not legally mandated, an adequately informed refusal, expressing compelling personal or religious beliefs, may be respected.
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