Ethics of Public Health

by

David Ross Buchanan

• LAST REVIEWED: 31 August 2015
• LAST MODIFIED: 31 August 2015
• DOI: 10.1093/obo/9780199756797-0073

Introduction

Discussion of the ethics of public health today emerges from the confluence of two streams of writings. A small number of influential scholars in public health have written articles to characterize the general ethical orientation of public health and have produced analyses of particular issues as they have arisen. A second stream has emerged more recently in the work of established bioethicists, who have examined the differences between medical ethics and public health ethics. In these newer works, a key point is that, whereas medicine focuses on the health of the individual, public health is concerned with the health of the entire population. Thus, in contrast to a principal fiduciary duty to the individual patient, public health ethics is founded on the societal responsibility to protect and promote the health of the population as a whole. In the United States, the beginnings of the field of bioethics are commonly traced to the late 1960s and 1970s, when the issues of defining brain death, especially as it pertained to the emerging capacity to perform organ transplants, and the notorious Tuskegee syphilis trial gained prominent public attention. It was not until the early 21st century, however, that these ethicists turned their attention to the distinct issues that arise when the level of analysis shifts from moral considerations of individual well-being to that of the population as a whole.

Background Works

Written by scholars who located themselves professionally within the field of public health, several notable works—Curran 1976, Faden and Faden 1978, Wikler 1978, and Lappé 1983—laid the foundation for how public health professionals have thought about the major ethical principles that orient the field of public health. One of the earliest pieces, Beauchamp 1976, is frequently given credit for the idea that the core ethical principle that guides public health is the cause of social justice. Curran 1976 introduces and debates the merits of the term “public health ethic” as distinct from medical ethics. Lappé 1983 is one of the first studies to make the case for the need for public health to go beyond utilitarianism (the greatest good for the greatest number, which is commonly criticized for its potential to sacrifice individuals rights for the common good), and for seeking to lay out criteria for determining when paternalistic policies (defined by the use of state powers to restrict individual choice, where the government assumes that it knows what is in the individual’s interest better than the individual himself) are justified. Faden and Faden 1978, Wikler 1978, and McGinnis 1985 set the terms for the debate about the degree to which individuals should be considered responsible for their own health, versus the degree to which it is beyond their control, with attendant implications for moral accountability and the problem of equity (e.g., the burden of tobacco taxes falls disproportionately on those who can afford it least).

• Beauchamp, Dan E.. 1976. Public health as social justice. Inquiry 13.1: 3–14.

  The seminal piece that is responsible for equating public health with social justice. Social justice is contrasted with “market justice,” which is said to characterize modern American society, with its emphasis on individual responsibility. In contrast, social justice holds that all individuals are entitled to equal protection from health hazards in the environment that are produced by the powerful.

• Curran, William. 1976. Bioethics and health ethics: A critical examination of the new terminology. American Journal of Public Health 66.5: 497–498.

  DOI: 10.2105/AJPH.66.5.497

  This article argues that people have public as well as private responsibilities for protecting health, such as getting immunized and not endangering the health of others. It also raises the question of the boundary between health behaviors that should be prohibited by law, and those that are part of the private sphere of individual freedom.

• Faden, Ruth, and A. I. Faden. 1978. The ethics of health education as public health policy. Health Education Monographs 6.2: 180–197.

  DOI: 10.1177/109019817800600203

  This article represents one of the first efforts to analyze the concept of voluntariness for public health audiences. It calls attention to the distinction between informational and persuasive communications, and their potentially distinct impacts on rationality and voluntariness. It also discusses the issue of “victim-blaming” (a popular term to indicate the absence of individual culpability).

• Lappé, Mark. 1983. Values and public health: Value considerations in setting health policy. Theoretical Medicine & Bioethics 4.1: 71–92.

  DOI: 10.1007/BF00489433

  This article analyzes six issues of public health policy (such as immunizations, compulsory treatment of infectious diseases, and limiting access to tobacco and alcohol). The paper points out the complexity of determining a reasonable balance among conflicting value considerations. An important paper for challenging the field to address the problems with any simple-minded resort to utilitarian thinking.

• McGinnis, Michael. 1985. The limits of prevention. Public Health Reports 100.3: 255–260.

  The section on ethical considerations raises the question of the basis of public jurisdiction over private behavior. It argues that state policies to regulate individual health behaviors that can harm others (e.g., drunk driving) are uncontroversial, while issues such as raising taxes on cigarettes raise equity issues. It concludes that policies designed to change individual behavior must be conscientiously crafted.

• Wikler, Daniel I. 1978. Persuasion and coercion for health: Ethical issues in government efforts to change life-styles. Milbank Memorial Fund Quarterly: Health and Society 56.3: 303–338.

  DOI: 10.2307/3349651

  This article provides an in-depth examination of the moral justification for the government’s role in promoting health behaviors, arguing that a simple-minded conclusion in favor of one side or the other is untenable. It cites the need to identify the conditions that would make such government policies morally acceptable, using examples that do not appear to be unreasonably coercive.