Ethics of Public Health Health Article

PUBLIC HEALTH ETHICS

Like ethics, public health has been a concern of human societies since antiquity. Plagues of contagious diseases have decimated populations since civilization began, and their significance has always been recognized. Because of the life-and-death importance of disease and the skill and training required to treat it, societies have always recognized the importance of physicians and have accorded them substantial jurisdiction over life and death. With this jurisdiction comes much power and, more importantly, much responsibility. This power and responsibility resulted in the first code of professional ethics, the Hippocratic Oath, which set out rules of conduct for physicians in their dealings with patients. Medical ethics, however, has evolved far beyond its roots and encompasses not only doctor-patient ethics, but also biomedical research ethics, the more socially based health ethics, and public health ethics.

Public health must balance the public good with the good of individuals. This perspective sometimes leads to conflict. For example, one of the most respected ethical traditions is doctor-patient confidentiality. However, in the case of a public health threat, such as a communicable disease, a tension naturally arises between the ethical responsibility to maintain confidentiality and the responsibility to protect the public health.

ETHICAL THEORY

Human interactions have the potential to result in ethical tensions. These tensions reflect a particular, unique context. In each context, opposing sides differ in that they subscribe to a particular set of values. Each side may be equally committed to, and able to defend, its moral judgment. How, then, are ethical tensions to be resolved when each situation is unique? The great volume of academic study in ethics over thousands of years has produced numerous approaches to ethical analysis. Fortunately, however, ethics has been studied well enough that some common threads have been recognized.

The dominant approach in public health has been to apply the utilitarian theory of ethics to resolving issues relating to public health. This theory focuses on achieving the greatest good for the greatest number of people and, thus, tends to focus on protecting the population rather than the rights of individuals (e.g., laws requiring the reporting of communicable diseases and the mandating of vaccination programs). Causing more good than harm is what drives public health decision making. However, in addition to this approach, other approaches are now commonly used. For example, duty-based ethical theory (deontology) and the four principles of bioethics as articulated by Tom L. Beauchamp and James R. Childress (1994) are helpful for both illustrating ethical tensions and serving as a basis for decision making. The four principles are:

1. Respect for autonomy. This is the principle of allowing people to make decisions about themselves for themselves. It is about respecting human dignity, believing in a person's ability to make good decisions, and is the opposite of paternalism.
2. Nonmaleficence. This means that actions should not harm others. It is derived from the Hippocratic injunction to "first, do no harm."
3. Beneficence. This is the mirror image of nonmaleficence, meaning that actions are taken in order to maximize benefits to individuals and society. It is the principle of doing good.
4. Justice. This refers to distributive justice and is the principle requiring that benefits and harms should be equally distributed among people. Related ideas are fairness, equity, and impartiality.

These principles provide a useful framework for informing actions, interventions, policies, and research in public health and its related disciplines. By themselves, however, they do not usually provide clear answers to ethical dilemmas. Instead, they are used as a framework for understanding the problem at hand. For example, should physicians be required to inform patients and gain their consent to test for HIV (human immunodeficiency virus) antibody status in a hospital? On the one hand, patients who suspect that they might be HIV-positive may refuse to allow themselves to be tested, potentially aggravating an already disastrous public health problem and perhaps exposing hospital personnel to HIV. In this case, the principle of beneficence would seem to obligate the state to insist on HIV testing regardless of patient consent. On the other hand, the principle of respect for autonomy would dictate that patients have a right to make their own decisions. Thus, there is a tension between the principles of beneficence and respect for autonomy. This is not unusual in the principle-based approach.

Tensions are resolved by taking the overall context of the issue of concern into consideration. Above all, an ethical analysis is not conducted against a checklist. Rather, it is a thoughtful appraisal of all related concerns, paying due cognizance to the broader social context that gave rise to the tension in the first place. A major contextual distinction is made between public health research and public health practice. For example, in research, studies of the broader determinants of health, such as socioeconomic factors, are of benefit. However, while the linking of income tax records with health records could provide a rich source of data, such research is prohibited. On the practical side, in communicable disease investigations, the utilitarian approach dominates. In sum, for research, individual privacy takes precedence over utility; in public health practice, utility takes precedence in that beneficence dominates over privacy.

More often than not, the four principles illustrate the tensions that exist and the issues that are involved rather than providing easy solutions to complex ethical questions. This is as it should be. Human interactions are complex and dynamic, requiring equally complex judgments in order to succeed. People are not machines whose actions are prescribed by a rigid set of rules. Learning how to do ethical analysis can be helpful in making an ethical decision.

A complementary approach to principle-based bioethics is the case-study approach, also called casuistry. In this approach, typical cases of ethical dilemmas and their results are recorded in an attempt to provide precedents to guide future decision making. It is analogous to the way that most modern democracies structure their legal systems. By analogy, one might think of written legislation as similar to the principle-based bioethics approach. As everyone knows, however, the law as it is written cannot address every individual situation. To resolve individual cases, there are courts that interpret legislation and set precedents through their judgments. This body of precedents forms the case law and assists judges in deciding future cases. Similarly, in bioethics, the principles of respect for autonomy, beneficence, nonmaleficence, and distributive justice are complemented by a body of case studies that help professionals understand how the principle-based approach can be applied. The American Public Health Association published a collection of case studies in Case Studies in Public Health Ethics (1997), in an attempt to document normative ethical practices.