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Introduction to Public Health Ethics 1- Background
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Introduction to Public Health Ethics 1- Background
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Introduction to Public Health Ethics 1: BackgroundJanuary 2014
A public health ethics must begin with This paper, the first of three, defines public health
recognition of the values at the core of public and reviews the history and development of
health, not a modification of values used to public health ethics, including its philosophical
guide other kinds of health care interactions underpinnings. The next papers will use this
(Baylis, Kenny, & Sherwin, 2008, p. 199). introduction as its starting point for a more
involved exploration of the theoretical and
Public health practitioners have long grappled philosophical background to public health ethics,
with ethical issues in their practice but, until the emerging frameworks for public health ethics,
recently, there have been few relevant ethics as well as a snapshot of where the field stands
frameworks that take into account the values and where it may be going.
base of public health. 1 Historically, those involved
in health care ethics and bioethics more generally What is Public Health?
have failed to provide public health practitioners
with guidance geared to their unique ethical “Public health is a contested concept” (Verweij &
For up-to-date knowledge relating to healthy public policy
concerns. Until relatively recently, a rights-based Dawson, 2007, p. 13) that has multiple meanings
deontological approach (Zahner, 2000), or the and is often misunderstood. Some understand
health care ethics principles of autonomy, public health to mean health care provided within
beneficence, non-maleficence, and justice the publicly funded health system. This
(Beauchamp & Childress, 1979), were invoked as misinterpretation occurs, in part, because public
the appropriate framework to support ethical health operates under the radar; people are not
public health practice. But, as an examination of aware of it until a crisis strikes and drastic public
the distinct goals and collective orientation of health measures need to be implemented. The
public health shows, health care ethics provides health care system, on the other hand, is highly
Briefing Note
neither an adequate theoretical foundation nor visible in our lives.
appropriate normative justification for public
health practice. This is because health care Definitions of public health include the following:
ethics focuses primarily on individuals, often in
clinical settings, whereas public health ethics is …the science and art of preventing
concerned primarily with populations, often in disease, prolonging life and promoting
community settings. health through the organized efforts of
society (Acheson, 1988, p. 1);
Public health ethics is a relatively new field of …what we, as a society, do collectively to
applied ethics (Bayer et al., 2007; Baylis, Kenny, assure the conditions in which people can
& Sherwin, 2008; Dawson & Verweij, 2007). be healthy (Institute of Medicine, 1988,
Although a few writers some years ago proposed p. 1);
the need for an ethics of public health
(Beauchamp, 1976; Lappe, 1986), the field of
public health ethics has only been claimed and
named as a distinct area of scholarship since the
late 1990s and into the new millennium (Kass,
2004). In fact, Kass says that the term “public
health ethics” was rarely used prior to the
year 2000.
1
This paper is based upon a section from a previously published book chapter. The author and the National Collaborating
Centre for Healthy Public Policy wish to thank Pearson Canada for allowing us to republish this copyrighted material in order
to make it available here. The original text is: MacDonald, M. (2013). Ethics of public health. In J.L. Storch, P. Rodney, and
R. Starzomski (Eds.), Toward a moral horizon: Nursing ethics for leadership and practice. Pearson Education Canada.
, 2 Briefing Note
Introduction to Public Health Ethics 1: Background
…an organized activity of society to promote, Who is the “Public” in Public Health?
protect, improve, and, when necessary,
restore the health of individuals, specified Childress et al. (2002) identify three notions of
groups, or the entire population. It is a public in public health; the numerical public, the
combination of sciences, skills, and values political public, and the communal public. The
that function through collective societal numerical public is the target population that refers
activities and involve programs, services, and to an aggregate of individuals to which population
institutions aimed at protecting and improving health measurements refer. The political public
the health of all the people (Last, 2007, refers to what is done collectively through public
p. 306). agencies and governments; it is the legislatively
designated responsibility of governments to promote
Common elements across all definitions include and protect health. Finally, the communal public
collective effort, societal responsibility, and attention includes all other forms of social and community
to social and environmental health determinants. In action to promote health that extend beyond the
all of them, the moral aim is to promote the health of practices of public health providers and agencies
the population as a social good that allows people to including non-governmental organizations, private
pursue other valued ends. Population health groups and citizens, and other collectives. The
assessment, health surveillance, health promotion, Healthy Cities/Communities movement worldwide
disease and injury prevention and health protection (Hancock, 1997) is an example of public health
tend to figure among the main functions pursued by action that involves a communal public.
public health (Canadian Institutes of Health
Research, 2003). More recently, as evidence of Jennings (2007) provides a more evocative notion of
growing health inequities accumulates, a concern public as “a community of individuals, intertwined
with vulnerable and marginalized populations has through complicated institutional and cultural
emerged. systems in (and through) which they act and carry
out their lives” (p. 36). He sees public as a
Because public health aims to improve the health of normative concept “that provides an account of how
whole communities, the strategies do not focus that system should be structured and how our lives
solely on individuals. Societally oriented in common ought to be composed and lived” (p. 36).
interventions, by their very nature, are provided by Thus, the public is much more than an aggregate of
local governing bodies such as state/provincial individuals. It is a complex system comprising a
governments, municipalities, or regional health network of interacting and interrelated elements. As
authorities. Providing safe water, ensuring a safe a whole, it has properties that are not reflected in its
and accessible food supply, public sanitation, and individual components. A simplistic view of a
taking action to control or prevent communicable population as an aggregate of atomistic elements is
diseases are just some of the public health rejected. Instead, Jennings argues, drawing on
interventions that require collective rather than Harré (1998), that an understanding of ethical
individual action. The collective nature of these conduct must encompass notions and concepts that
interventions often requires legislative authority and “reflect the relational nature of the human self or
may infringe on the rights of individuals, thus raising actor and the contextual social nature of the actor’s
distinctive ethical challenges. meaningful, symbolically mediated relationships with
others” (p. 37). As we shall discuss in the next
Because public health aims to improve the health paper, these ideas about the meaning of public and
of whole communities, the strategies do not focus the relational nature of persons undergird emerging
solely on individuals. The collective nature of perspectives in both public health and feminist
these interventions often requires legislative ethics. It is in this relational, social sense underlying
authority and may infringe on the rights of the concept of public that we find a key inspiration
individuals, thus raising distinctive ethical for public health ethics, and in which the distinction
challenges. between public health ethics and traditional health
care ethics is most clear.
Tel: 514 864-1600 ext. 3615 • Email: ncchpp@inspq.qc.ca • Twitter: @NCCHPP • ncchpp.ca
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