An Overview of Ethics and How Public Health Does Its Work
Abstract and Keywords
Modern public health in the United States is conducted by a network of private, public, local, state, tribal, and federal organizations, agencies, individuals, and communities. The ethical mandate of public health has always been to protect and promote the health and well-being of the population. This chapter introduces the ways in which public health actors work to achieve those goals, and how their efforts can be squared with the quintessential American value of personal liberty, as well as with the increasing recognition of the importance of justice as a foundation for public health. It also provides chapter overviews for the related section of The Oxford Handbook of Public Health Ethics, which includes chapters on the ethics and public health system, public health interventions, and public health law and regulation.
Modern public health in the United States is conducted by a network of private, public, local, state, tribal, and federal organizations, agencies, individuals, and communities. The seeds of this network were planted in the eighteenth century, when local efforts led to the isolation and quarantine of humans and cargo arriving from overseas, with the goal of protecting people from potential disease (IOM, 1988). As science advanced and populations grew, local public health took on the protection of the health and welfare of citizens in additional ways. In general, early American public health efforts were dominated by local- and state-level efforts directed at the needs of local citizens. The role of the federal government in public health began with the establishment of the first marine hospital in 1801 (HHS, 2017). In 1870 the administration of a number of marine hospitals was centralized under the Marine Hospital Service (HHS, 2017). Based in port cities of the United States, the goal of the service was to attend to the health and welfare of merchant seamen. The Marine Hospital Service became the US Public Health Service early in the 20th century (IOM, 1988). Yet, in many ways, states and localities in the United States have maintained considerable responsibility for protecting the public’s health.
The ethical mandate of public health has always been to protect and promote the health and well-being of the population. Yet such a goal has sometimes put the practice of public health in direct conflict with the quintessential American value of personal liberty. As such, a recurring ethics question for public health surrounds the degree to which the state can infringe on the autonomous choices of the individual in order to protect or promote the public’s health (Bayer and Moreno, 1986; Childress et al., 2002). (p. 60) The quarantine and isolation of goods and humans centuries ago resulted in questions about the role of public health in regulating commerce and the limits that ought to be placed on infringement of an individual’s movements. As populations grew, so did the need for the establishment and upkeep of sewage systems. Identifying who should be responsible for the funding of such infrastructure led to the entanglement of public health with private and commercial interests.
More contemporary perspectives on public health argue that the protection of the public’s health ought to be undergirded by a commitment to social justice. In this view, efforts should be made to address health disparities as well as to avoid particular public health efforts that might further disadvantage already disadvantaged groups (Beauchamp, 1976; Powers and Faden, 2008). Today, the US public health system affects every American household and involves activities such as monitoring early warning systems for infectious disease outbreaks and assuring access to childhood vaccination.
The following three chapters in this section of The Oxford Handbook of Public Health Ethics examine public health ethics through the lenses of the US public health system, public health interventions, and public health law and regulation, respectively. The chapters are introduced below.
In “The US Public Health System and Ethics,” Debra DeBruin and Jonathon P. Leider begin with an introduction to the depth and breadth of the public health system. The authors note that the public health system is generally “invisible” to the general public, at least until something goes wrong, such as an outbreak of disease or the contamination of a water system. They argue that ethical issues pervade the conduct of public health, from the development of national strategies to day-to-day decisions made by local health officers. They conclude with a focus on the ethics of pandemic influenza planning from the perspective of a local health department, emphasizing the challenge of how best to respond to a public health emergency without exacerbating health disparities among the populations affected.
One mechanism by which public health authorities tackle the control and prevention of disease is through the delivery of behavioral interventions. Initially, as outlined above, these interventions targeted the control of communicable disease. While the control and prevention of communicable diseases remains an ongoing focus of public health efforts, the second chapter in this section brings attention to the ethical challenges in the prevention of chronic disease, which presents a growing burden on the health of populations in high-income as well as low- and middle-income settings (NCHS, 2016; Wang et al., 2016).
In “Public Health Interventions: Ethical Implications,” David R. Buchanan first distinguishes public health interventions from clinical care delivery. He then argues that there are at least two ways to parse public health interventions. The first is to determine if they (p. 61) are infectious or chronic; the second examines whether interventions are best directed at individuals (e.g., educational) or at the environment (e.g., improving neighborhood safety). Noting that 85 percent of morbidity and mortality in high-income countries is related to chronic disease and its complex web of risk factors, Buchanan focuses most of the chapter on ethics issues related to the prevention and control of chronic disease. He notes that this area raises not only the classic ethical tension between what is best for the community versus what promotes the liberty of the individual, but also more broadly requires attention to social determinants of health. Chronic disease highlights how varying levels of disadvantage can predict the ability of an individual or community to succeed in efforts to prevent or control noncommunicable disease, raising new questions regarding the role of public health in addressing systemic disadvantage.
Buchanan then elaborates on the differences between educational and environmental interventions, highlighting the challenge of understanding the interaction among individual behaviors, social determinants, and the built and natural environment on the health of individuals and the communities in which they live. He delineates three key ethical considerations related to implementing public health interventions directed at chronic disease: the potential individual and community harms to avoid, attention to distributive and social justice, and how to buttress rather than diminish social solidarity.
Public health law has been used as a powerful tool to restrict and promote behaviors of individuals and communities in efforts to enhance the health of the population. The law has been a central tool of public health from the earliest of years of public health in the service of controlling the spread of communicable disease. The landmark US Supreme Court case Jacobson v. Commonwealth of Massachusetts (197 U.S. 11 ) concluded that the state could require an individual to be vaccinated against communicable disease despite the informed decision of the individual to refuse. The court ruled that the interests of the state in preventing smallpox outweighed the individual’s right to refuse vaccination (Colgrove and Bayer, 2005). Today, public health law, in its many forms, plays a key role in the restriction and regulation of actions taken by individuals, communities, agencies, and organizations to protect and promote health and well-being. The authors of the final chapter in this section knit the two threads of this section—communicable and noncommunicable disease—together by highlighting contemporary examples of the role of law in the age-old challenge of preventing infectious disease and the more modern challenges of obesity and tobacco use.
In “The Intersection of Law, Ethics, and Public Health in the United States,” Stacie P. Kershner and Leslie E. Wolf begin by distinguishing health care law from public health law. The former, just as with health care in general, focuses on the relationship between physicians and their patients. The latter focuses on the powers and duties of the state to promote the health of populations. Next, the authors delineate the multiple sources of public health laws: federal and state constitutions, statutes, regulations, court decisions, and executive orders. They introduce the Jacobson case as a milestone in public health law that put the court in the position of balancing individual liberty with the health and well-being of the community. The court concluded that individual liberty could be (p. 62) infringed when the proposed measure is necessary to avert a threat to public health, and when the measure is reasonable and proportional given the threat of harm to be averted. The authors note that while public health law often creates limits around potential actions that a public health authority may take, public health ethics can help identify the best options among permissible actions. Kershner and Wolf conclude the chapter with examples of public health law in action in the context of infectious disease prevention, tobacco control, and the prevention of obesity and related chronic diseases.
Over the last two centuries, significant advances have improved population health. Progress has been facilitated through a combination of regulation, public policy, education, and environmental change. Nonetheless, the enterprise of public health has faced, and will continue to face, ethical challenges. Public health must navigate between the promotion of public health and the degree to which the liberty of individuals can be restricted, while also attending to underlying commitments to justice. It also must continue to contend with the extent to which it can regulate the behavior of individuals and communities, or change the environment, to promote the health of populations.
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