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Public Health Ethics: Mapping the Terrain

Published online by Cambridge University Press:  01 January 2021


Public health ethics, like the field of public health it addresses, traditionally has focused more on practice and particular cases than on theory, with the result that some concepts, methods, and boundaries remain largely undefined. This paper attempts to provide a rough conceptual map of the terrain of public health ethics. We begin by briefly defining public health and identifying general features of the field that are particularly relevant for a discussion of public health ethics.

Public health is primarily concerned with the health of the entire population, rather than the health of individuals. Its features include an emphasis on the promotion of health and the prevention of disease and disability; the collection and use of epidemiological 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.

Copyright © American Society of Law, Medicine and Ethics 2002

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Our definition builds on the definition of health systems offered by the World Health Organization: Health systems include “all the activities whose primary purpose is to promote, restore, or maintain health.” See World Health Report 2000 Health Systems: Improving Performance (Geneva: World Health Organization, 2000): at 5.Google Scholar
Committee for the Study of the Future of Public Health, Division of Health Care Services, Institute of Medicine, The Future of Public Health (Washington, D.C.: National Academy Press, 1988): at 1.Google Scholar
We recognize that there are different views about the ultimate moral justification for the social institution of public health. For example, some communitarians appear to support public health as an instrumental goal to achieve community. Others may take the view that the state has a duty to ensure the public's health as a matter of social justice. Although these different interpretations and others are very important for some purposes, they do not seriously affect the conception of public health ethics that we are developing, as long as public health agents identify and inform others of their various goals.Google Scholar
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For some other approaches, see Nieburg, P. Gaare-Bernheim, R. Bonnie, R., “Ethics and the Practice of Public Health,” in Goodman, al., eds., Law in Public Health Practice (New York: Oxford University Press, in press)Google Scholar
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We do not explore here the overlaps among public health ethics, medical ethics, research ethics, and public policy ethics, although some areas of overlap and difference will be evident throughout the discussion. Further work is needed to address some public health activities that fall within overlapping areas — for instance, surveillance, outbreak investigations, and community-based interventions may sometimes raise issues in the ethics of research involving human subjects.Google Scholar
Recognizing universalizability by attending to past precedents and possible future precedents does not preclude a variety of experiments, for instance, to determine the best ways to protect the public's health. Thus, it is not inappropriate for different states, in our federalist system, to try different approaches, as long as each of them is morally acceptable.Google Scholar
This justificatory condition is probably the most controversial. Some of the authors of this paper believe that the language of “necessity” is too strong. Whatever language is used, the point is to avoid a purely utilitarian strategy that accepts only the first two conditions of effectiveness and proportionality and to ensure that the non-utilitarian general moral considerations set some prima facie limits and constraints and establish moral priorities, ceteris paribus.Google Scholar
For another version of these justificatory conditions, see Beauchamp, T.L. Childress, J.F., Principles of Biomedical Ethics, 5th ed. (New York: Oxford University Press, 2001): at 19–21. We observe that some of these justificatory conditions are quite similar to the justificatory conditions that must be met in U.S. constitutional law when there is strict scrutiny because, for instance, a fundamental liberty is at stake. In such cases, the government must demonstrate that it has a “compelling interest,” that its methods are strictly necessary to achieve its objectives, and that it has adopted the “least restrictive alternative.” See Gostin, supra note 4, at 80–81.Google Scholar
Of course, this chart is oversimplified, particularly in identifying only voluntary and mandatory options. For a fuller discussion, see Faden, R. Powers, M. Kass, N., “Warrants for Screening Programs: Public Health, Legal and Ethical Frameworks,” in Faden, R. Geller, G. Powers, M., eds., AIDS, Women and the Next Generation (New York: Oxford University Press, 1991): 326.Google Scholar
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See Faden, Geller, Powers, , supra note 11 Gostin, , supra note 4, at 199–201.Google Scholar
In rare cases, it may be ethically justifiable to limit the disclosure of some information for a period of time (for example, when there are serious concerns about national security, about the interpretation, certainty, or reliability of public health data; or about the potential negative effects of disclosing the information, such as with suicide clusters).Google Scholar
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See, for example, the discussion in Kawachi, I. Kennedy, B.P. Wilkinson, R.G., eds., Income Inequality and Health, vol. 1 of The Society and Population Health Reader (New York: The New Press, 2000).Google Scholar
Mann, J.M., “Medicine and Public Health, Ethics and Human Rights,” The Hastings Center Report, 27 (May-June 1997): 613, at 11–12. Contrast Gostin, , supra note 4, at 21. For a fuller analysis and assessment of Mann's work, see Gostin, L. O., “Public Health, Ethics, and Human Rights: A Tribute to the Late Jonathan Mann,” Marks, S.P., “Jonathan Mann's Legacy to the 21st Century: The Human Rights Imperative for Public Health,” and Gostin, L.O., “A Vision of Health and Human Rights for the 21st Century: A Continuing Discussion with Stephen P. Marks,” Journal of Law, Medicine, and Ethics, 29, no. 2 (2001): 121–40.CrossRefGoogle Scholar
Mann, , supra note 21, at 10. Mann thought that the language of ethics could guide individual behavior, while the language of human rights could best guide societal-level analysis and response. See Mann, , supra note 21, at 8; Marks, supra note 21, at 131–38. We disagree with this separation and instead note the overlap of ethics and human rights, but we endorse the essence of Mann's position on human rights.Google Scholar
See Gostin, , supra note 4, at 21.Google Scholar
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