An Overview of Conceptual Foundations, Ethical Tensions, and Ethical Frameworks in Public Health
Abstract and Keywords
The field of public health ethics has plural foundations in major normative ethical theories, principally consequentialism and deontology, and in ethical concepts such as social justice and human rights. This overview provides some basic background on ethical theory and introduces chapters in the related section of The Oxford Handbook of Public Health Ethics. The four chapters together elucidate the moral foundations of public health ethics. One chapter characterizes public health and describes the ethical challenges raised by its distinctive characteristics, while the next examines the ways in which public health interventions may be morally justifiable. The following two chapters focus, respectively, on justice and human rights, considering the operation of each not only as moral foundations, but also as side constraints in frameworks of public health ethics.
Public health is fundamentally concerned with promoting the health of populations through the prevention of disease and injury. It is, at its core, a moral endeavor, because the end it seeks is the advancement of human well-being. Health has intrinsic value inasmuch as it is partly constitutive of individual flourishing. It also has instrumental value in providing some of the conditions necessary for the proper functioning of populations. As Lawrence Gostin (2004, 511) notes, “Without minimum levels of health, people cannot engage in social interactions, participate in the political process, exercise rights of citizenship, generate wealth, create art, and provide for common security.”
But while the pursuit of public health is motivated by the aspiration to improve human welfare, there are several different normative lenses through which we can understand the moral foundation of the public health enterprise. These alternative understandings of the foundational values of public health in turn bear on how we articulate and address the ethical challenges that arise in public health.
(p. 6) Consequentialism and Public Health
According to consequentialist ethical theories, the sole justification for an act is the state of affairs it brings about, and the right action or policy is the one that maximizes the particular good (e.g., pleasure, happiness, or welfare) that is sought. Consequentialism might appear to be well suited to public health, given that the goal of public health is to enhance the welfare of populations. And, indeed, the consequentialist perspective does inform some approaches to public health policy. For example, it underlies a cost-effectiveness approach to resource allocation that is embraced by many health economists, and it seeks to maximize the number of healthy life years in the population as a whole through a distribution of resources that results in the most “quality-adjusted life years” (QALYs).
A standard form of moral objection against consequentialism, however, is that a strict adherence to it would, in principle, permit acts that are reasonably considered to be violations of distributive justice and personal autonomy. With respect to concerns about distributive justice, consider the possible use of QALYs as the sole metric to guide health resource allocation, combined with a strictly consequentialist distributive principle of maximizing the number of QALYs gained. QALYs assign a quality-weighted value between 0 and 1 to each year of life under particular health conditions. If, for example, people would accept a 20 percent risk of death to be cured of blindness, one year of life with blindness would be worth 0.8. Allocations based on a strictly consequentialist objective of maximizing the number of QALYs gained would thus give priority to a program that saves the lives of ten sighted persons rather than ten blind persons. But while this distribution might produce the greater overall number of QALYs, there is good reason to consider it grossly unjust, on the grounds that each person’s life has equal moral worth. As to concerns about personal autonomy, some examples of public health policies that a consequentialist outlook could warrant, but that many would deem violations of individual rights, include quarantine regulations that offer little due process in public health emergencies, policies that interfere with risky but voluntary and exclusively self-regarding lifestyle choices, and public health surveillance that invades people’s privacy.
Deontology and Public Health
One way of overcoming the moral concerns associated with consequentialism is to recognize deontological constraints on the pursuit of a good. On deontological ethical theories, what makes an act right are the intrinsic features of the act rather than the state of affairs that it produces. On deontological approaches (sometimes called duty-based approaches), we have duties toward others (and ourselves) that prohibit certain acts regardless of the good consequences those acts may yield. These duties are often taken to (p. 7) include, among other things, acting in a manner that conforms to norms of fairness and that manifests respect for personal autonomy. Thus, a deontological approach to public health ethics would reject policies that violate obligations grounded in autonomy or distributive justice, even if those policies would maximize population health.
The most prominent frameworks for public health ethics incorporate both consequentialist and deontological considerations; that is, they recognize both that the general justification for the public health enterprise is to produce good health outcomes, and that the demands of justice and respect for individual liberty and privacy rights place limits on the kinds of public health policies that are permissible (Childress et al., 2002; Kass, 2001; Marckmann et al., 2015). These pluralist accounts of the foundational values of public health avoid standard moral objections against consequentialism but give rise to continuing challenges about what weight to attach to each of the values when they come into conflict.
Social Justice and Public Health
While public health ethics frameworks frequently appeal to justice as a principle that operates as a side constraint on the goal of maximizing good health outcomes, some theorists view justice as the moral foundation of public health. One such account posits that health is one of several “essential dimensions of well-being” (which also include respect, self-determination, attachment, personal security, and reasoning) that justice aims to secure (Powers and Faden, 2008). On this view, justice requires that everyone have a sufficient amount of each of the essential dimensions of well-being. This entails both that public health is a direct requirement of justice and that particular attention be given to the most disadvantaged members of society.
Human Rights and Public Health
Human rights comprise, in concept, a high-priority set of moral claims said to be universally held by all people (Nickel, 2017). International documents such as the Universal Declaration of Human Rights (1948) and the International Covenant on Economic, Social and Cultural Rights (1966) recognize a human right to health. Other internationally recognized human rights are focused on societal goods that are determinants of health, such as personal security and education. Advocates for human rights to health and to the determinants of health characterize such rights as morally foundational to public health (Gruskin and Dickens, 2006; Mann, 1997). Moreover, some human rights, such as the right to freedom from discrimination recognized in the Universal Declaration of Human Rights and related documents, can be framed as moral constraints on public health activities (Mann et al., 1994).
(p. 8) The normative accounts outlined above represent some of the major approaches to understanding the moral foundations of public health ethics. Other accounts appeal to, among other things, civic virtue and the promotion of the common good (Jennings, 2007), an ethics of care (Roberts and Reich, 2002), and obligations grounded in a conception of persons as interrelated social beings (Kenny, Sherwin, and Baylis, 2010).
Whatever position one adopts about the moral foundations of public health, many questions remain regarding the specification and application of its foundational values. What are the boundaries of the population whose health we should promote? What principles of distributive justice should govern resource allocation and prioritization? Under what conditions are public health measures that interfere with liberty justified? What is the basis for asserting a human right to health, and what demands does such a right make on public health institutions, policies, and practices? This section of The Oxford Handbook of Public Health Ethics explores these and related issues through four chapters, introduced below.
In “Public Health Programs and Policies: Ethical Justifications Distinctive Challenges of Public Health Ethics,” Ruth R. Faden, Sirine Shebaya, and Andrew W. Siegel provide an overview of the challenges of public health ethics. They begin by identifying four distinctive characteristics of public health: (1) its focus on the health of populations rather than individuals; (2) its particular commitment to the prevention of disease and injury, rather than with their diagnosis and treatment; (3) its intrinsic orientation toward outcomes; and (4) its reliance on government action for its promotion.
The authors describe how each of these features of public health gives rise to important ethical issues. First, the focus on populations raises issues about the object of public health, especially the question of how broadly we understand the population that public health serves. Often, the relevant “public” is understood in terms of the population of a particular nation-state. But Faden, Shebaya, and Siegel note that this may be problematic, both because diseases cross borders and because there may be moral obligations to promote health that transcend the boundaries of nation-states. Second, the public health focus on prevention raises issues about how future health gains should be weighed against current health gains. Third, the orientation toward outcomes prompts some of the questions about the moral foundations of public health ethics discussed above in the section on “Human Rights and Public Health”—in particular, whether the general justification for public health is consequentialist, or whether we pursue good public health outcomes to fulfill the demands of social justice. Finally, the reliance on government action supported by the force of law raises questions about the justification for the use of state coercion to advance public health, especially where it involves measures that interfere with individual liberty.
(p. 9) In “Public Health Programs and Policies: Ethical Justifications,” Faden and Shebaya examine the kinds of moral justification that may be marshaled in support of specific public health interventions. They identify five such justifications:
1. The overall benefit a public health measure produces.
2. The collective efficiency an intervention provides by coordinating action to ensure population-wide compliance.
3. Fairness in the distribution of the burdens of disease and disability.
4. The “harm principle,” according to which the only justification for limiting a person’s liberty is the prevention of harm to other persons.
5. Paternalism, which is the thesis that a restriction on individual liberty is acceptable if it is necessary to prevent harm or produce a benefit to the agent involved.
The first three justifications concern the justification of public health policies that do not directly benefit all members of the population, while the last two concern the justification of public health measures that interfere with individual liberty. Faden and Shebaya note that there will often be more than one justification of a policy, and they critique frameworks that place a disproportionate emphasis on the liberty-limiting aspects of policies.
These two chapters examine in detail concepts of central moral importance for public health ethics: justice and human rights. As noted above, considerations of both justice and human rights may operate as either side constraints or as moral foundations in frameworks of public health ethics.
In “Justice and Public Health,” Govind Persad maps the landscape of justice as applied to public health. He first describes three prominent metrics regarding what to measure in assessing the justice of states of affairs and policy choices; he then describes seven distinct principles regarding who gets what under just distributions of what is measured. The chapter illustrates the overarching point that any metric may be combined with any distributive principle. The example of QALY-oriented strict consequentialism sketched above in the section on “Consequentialism and Public Health” combines a species of “welfarist” metric—purporting to quantify and compare how people experience various health states–with the distributive principle of maximization. By contrast, Powers and Faden’s (2008) theory combines a metric of well-being achieved in multiple core dimensions (health being one) with a “sufficientarian” distributive principle aiming for universal achievement of well-being above a certain threshold in all dimensions. Persad also discusses the intersection of justice with individual rights; the geographical, temporal, and biological scope of justice; whether justice applies to individual as well as institutional choices; and strategies for resolving disagreements about justice.
In “Human Rights and Public Health Ethics,” S. Matthew Liao offers an account of what human rights are, how they can be morally justified, and how they correspond to moral obligations in public health practice and policymaking, with special attention to the idea of a human right to health. Liao’s chapter outlines the “fundamental conditions (p. 10) approach,” which holds that “human rights protect the fundamental conditions for pursuing a good life. The fundamental conditions comprise various goods, capacities, and options that human beings qua human beings need, whatever else they might need, in order to pursue certain basic activities” (Liao, this volume). The chapter uses the fundamental conditions approach (Liao, 2015) to develop a conception of “basic health” as the object of the human right to health (which also entails rights to “adequate nutrition, basic health care, and basic education”), and argues that corresponding duties to support effective public health measures are held by everyone, not only governments.
The field of public health ethics has plural foundations in major normative ethical theories, principally consequentialism and deontology, and in ethical concepts such as social justice and human rights. This overview provides some basic background on ethical theory and introduces chapters in the related section of The Oxford Handbook of Public Health Ethics. Those chapters together elucidate the moral foundations of public health ethics that are essential in any approach to ethical issues arising in the diversity of public health topic areas.
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