Public Health Ethics: an Introduction and Overview
Abstract and Keywords
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. Vexing ethics issues are inherent in all aspects of public health practice and policy. This chapter provides a concise overview of the topics and issues examined in the Oxford Handbook of Public Health Ethics.
Natural disasters and cholera outbreaks. Ebola, SARS, and concerns over pandemic flu. HIV and AIDS. E. coli outbreaks from contaminated produce and fast foods. Threats of bioterrorism. Contamination of compounded drugs. Vaccination refusals and outbreaks of preventable diseases. These are just some of the headlines from the last thirty-plus years highlighting the essential roles and responsibilities of public health, all of which come with ethical issues and the responsibilities they create.
Public health has achieved extraordinary successes. Life-threatening diseases that were once scourges—smallpox and diphtheria, for example—are either non-existent or far less prevalent (CDC, 1999), particularly in wealthier countries, and infant mortality rates are vastly lower in most parts of the world. Motor vehicles, workplaces, and the food supply are all considerably safer than they once were (Berkeley Wellness, 2017). And yet these successes also bring with them ethical tension. Not all public health successes are equally distributed in the population, and extraordinary health disparities between rich and poor still exist. The most successful public health programs sometimes rely on policies that, while improving public health conditions, also limit individual rights. Moreover, the work of public health is always challenged by inadequate resources, raising the question of how best to allocate limited resources.
Resources, financial and otherwise, may only be available to support programs that benefit a particular population or neighborhood, or that reflect a higher public health priority. Which community should receive an asthma prevention program? How should we weigh the interests of programs targeted to children against those targeted for older persons? Which health systems and what types of structures most equitably improve the public’s health in low-income countries? Should public resources be dedicated to bioterrorism preparedness or obesity prevention programs? How should vaccines, antivirals, and other life-saving resources be allocated during a global pandemic? Public health practitioners and policymakers face these and other questions of ethics routinely in their work, and they must navigate their sometimes competing responsibilities to the health of the public with other important societal values, such as privacy, autonomy, and prevailing cultural norms.
(p. xxxii) Whereas medical ethics has a rich history dating back thousands of years, scholarly interest in public health ethics dates only to more recent decades (Kass, 2001; Childress et al., 2002). While overarching ethical commitments of public health are similar to those of medicine, the emphasis is quite different. Public health focuses its attention primarily on population and community health, often engaging in collective action or targeting societal conditions that contribute to better or worse health. This shift in emphasis inevitably leads public health to give moral priority to utility and to equity in ways that medical ethics need not.
A number of years ago, we realized that while there are volumes in the Oxford Handbook series devoted to a range of areas in bioethics, including the Handbooks of Bioethics, Clinical Research Ethics, Reproductive Ethics, Psychiatric Ethics, and Animal Ethics, none are devoted to public health ethics. The time has come. We are pleased to bring together a collection of some of the world’s and countries’ leaders in public health and ethics to put forward a handbook on a wide range of key issues in public health ethics today.
The 15 sections of the volume begin with 2 sections that discuss the conceptual foundations, ethical tensions, and ethical frameworks of and for public health and how public health does its work. The following 13 sections examine the application of public health ethics considerations and approaches across a broad scope of public health topics. While chapters are arranged into topical sections, each chapter is designed to serve as a stand-alone contribution. This approach makes the book, its sections, and individual chapters useful in a range of applications as part of course materials, or as a reference for students, scholars, and public health professionals.
For this volume, we recruited 11 section editors, primarily from among our talented colleagues at the Johns Hopkins Berman Institute of Bioethics. Together, we identified the most important and pressing topics to be covered in a comprehensive handbook and potential authors who could contribute their expertise to this effort, including leading scholars working in public health ethics and authorities working in relevant areas of public health. The section editors then recruited and worked with chapter authors to identify central issues and ethical challenges within distinct areas in our field. Authors were given substantial freedom in approach and were expected to share their perspectives on their assigned topics.
The resulting volume includes 73 chapters covering many topics from varying perspectives. We recognize that there may be some omitted areas—an acknowledgment of the breadth of activities and areas that define public health in the United States and globally, and the important diversity of ethics issues that occur within them. Indeed, we encourage others to contribute to what this project has begun.
Berkeley Wellness. 2017. “CDC: The Top 10 Public Health Achievements in the 20th Century.” http://www.berkeleywellness.com/healthy-community/health-care-policy/article/cdcs-top-10-public-health-achievements-20th-century.
CDC (US Centers for Disease Control and Prevention). 1999. “Achievements in Public Health, 1900–1999 Impact of Vaccines Universally Recommended for Children—United States, 1990–1998.” Morbidity and Mortality Weekly Report 48(12): 243–248.Find this resource:
Childress, J. F., Faden, R. R., Gaare, R. D., Gostin, L. O., Kahn, J., Bonnie, R. J., et al. 2002. “Public Health Ethics: Mapping the Terrain.” Journal of Law, Medicine and Ethics 30(2): 170–178.Find this resource:
Kass, N. E. 2001. “An Ethics Framework for Public Health.” American Journal of Public Health 91(11): 1776–1782. doi:10.2105/AJPH.91.11.1776. (p. xxxiv) Find this resource: