Ethics in Public Health

Public Policy, Law, and Ethical Theory

There is a societal expectation that the government should assume some degree of responsibility for protecting public health. In the United States, public health institutions have legal (police) powers. Legislative statutes, court cases, and administrative policies frequently address public health matters. Ethics, public policy, and law are overlapping sources of guidance for determining acceptable behavior for citizens, professionals, and government officials, allocating limited resources, and defining individual rights and responsibilities. Policies may be inconsistent or outmoded, they may not always reflect society's moral consensus, and they do not provide guidance for decision making in every situation. Some laws may even be considered by certain citizens to be unethical. For these reasons, careful ethical analysis is necessary to provide additional legitimacy for state-sponsored public health activities.

Ethical theories and frameworks are conceptual tools to aid decision making and the evaluation of ethical arguments. They do not provide automatic solutions to complex problems. Theories identify and justify basic moral principles, but in a given situation, facts must be considered, and principles or values can sometimes conflict.

The leading ethical framework in medicine is principlism. The four prima facie principles of respect for autonomy, beneficence, nonmaleficence, and justice are widely recognized as shared professional values from which ethical rights and duties can be derived. Public health shares a commitment to these ethical principles but may weigh them differently in a particular circumstance due to an emphasis on collective [Page 347]risks and benefits. Additional principles such as utility and consideration of the common good are also characteristic of public health.

Several ethical theories are also relevant to public health. Kantian deontology connects morality and reason; certain actions are intrinsically right or wrong and, therefore, ethically mandated or prohibited. Kant emphasizes individual rights and is perhaps best known for arguing that no person should ever be treated as a means to another's end, but instead, all persons should be treated as ‘ends in themselves.’ This emphasis on respect for persons provides balance against considerations of utility and efficiency. In contrast to deontology, for which consequences are relevant only if the action is morally permissible, utilitarianism presupposes that actions are right insofar as they promote the greatest good for the greatest number. For the utilitarian, expected consequences are the primary consideration in decision making. Public health is often described as utilitarian because policies and interventions aim to maximize aggregate health outcomes. However, both Kantian deontology and utilitarianism are somewhat limited in their application to public health because they do not consider collective social goals. Communitarian theory, which asserts that ethics cannot be separated from the shared history, traditions, customs, and institutions of particular communities, may be more consistent with the ethical perspective of public health. Human rights theory may also provide a normative ethical framework for public health, emphasizing universal civil, political, and social rights and recognizing socioeconomic, cultural, and environmental influences on health.

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