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PUBLIC HEALTH MATTERS An Ethics Framework for Public Health
| Nancy E. Kass, ScD
vital health statistics.2 Governments began
More than 100 years ago, public health began as an organized discipline, its purpose being to im-
conducting investigations of housing condi-
prove the health of populations rather than of individuals. Given its population-based focus, however,
tions and garbage heaps and mapping them
public health perennially faces dilemmas concerning the appropriate extent of its reach and whether in relation to outbreaks of disease,2 and by
its activities infringe on individual liberties in ethically troublesome ways. In this article a framework for the end of the 19th century, state and local
ethics analysis of public health programs is proposed. boards of health were being created to en-
To advance traditional public health goals while maximizing individual liberties and furthering so- force sanitary regulations.1(pp60–61)
cial justice, public health interventions should reduce morbidity or mortality; data must substantiate By the early 20th century, public health
that a program (or the series of programs of which a program is a part) will reduce morbidity or mor- was seen as cost-effective as well as useful,2
tality; burdens of the program must be identified and minimized; the program must be implemented and more money was directed to public
fairly and must, at times, minimize preexisting social injustices; and fair procedures must be used to health programs. During World War II, given
determine which burdens are acceptable to a community. (Am J Public Health. 2001;91:1776–1782) the need for a healthy population for the mili-
tary, the US Public Health Service established
the Center for Controlling Malaria in the War
Public health as an organized discipline began clinical practice and research. A first attempt Areas, later the Centers for Disease Control
more than 100 years ago, with the goal of im- at such a framework is offered here. and Prevention. Epidemiology developed as
proving the health, primarily, of populations the science of public health, to study “the dis-
rather than of individuals. Given its popula- PUBLIC HEALTH tribution and determinants of health-related
tion-based focus, however, public health con- states or events in defined populations and [to
tinually faces dilemmas concerning the appro- Public health is the societal approach to apply this knowledge] to the control of health
priate extent of its reach and at what point protecting and promoting health. Generally problems.”3(p42)
the work of public health professionals is in- through social, rather than individual, actions, Today, public health practitioners use
fringing on individual liberties in ethically public health seeks to improve the well-being tools in addition to epidemiology to accom-
troublesome ways. Nonetheless, there have of communities. By maintaining a safe water plish their work, still focusing primarily on
been few attempts to articulate an ethics of supply, immunizing schoolchildren, or engag- communitywide, typically prospective, ap-
public health. ing in epidemiologic research, public health proaches to improve health. Some public
Bioethics, as a discipline, helps health care seeks to ensure societal conditions under health functions—surveillance, vital statistics,
professionals identify and respond to moral which people can lead healthier lives,1 mini- disease and injury reporting, and disease
dilemmas in their work. In this article I sug- mizing threats to our health “that can be registries—relate to epidemiology and the
gest that the contexts out of which bioethics averted or lessened only through collective collection of data. In addition, practitioners
emerged—medical care and human research— actions aimed at the community.”1(p20) The investigate outbreaks, conduct contact trac-
were oriented toward a different set of con- providers of public health interventions often ing, provide health education and other pre-
cerns than those typically arising in public are governments, rather than private practi- ventive interventions, and conduct research
health. While the founders of bioethics articu- tioners. Indeed, the provision of health serv- related to public health. Last, public health
lated principles equally relevant for public ices, generally the domain of medicine, be- professionals sometimes create or enforce
health, the more specific action guides and comes the responsibility of public health health-related regulations and legislation, for
codes of health care ethics that have followed departments when services are provided by example, mandating screening, treatment,
are an imperfect fit for public health. Codes public clinics or hospitals. immunizations, or—rarely—quarantine.
of medical and research ethics generally give Public health interventions date back more States’ authority to pass laws to improve the
high priority to individual autonomy, a prior- than 3 centuries. In 1701, Massachusetts public’s health dates to the 19th century and
ity that cannot be assumed to be appropriate passed laws for isolation of smallpox patients is referred to as the “police power”: “coercive
for public health practice. and quarantine of ships.1(p57) In the early action under state authority to encourage edu-
A framework of ethics analysis geared 1800s, Edward Chadwick demonstrated in cational efforts . . . seize property, close busi-
specifically for public health is needed, both England that differences in social conditions nesses, destroy animals, or involuntarily treat
to provide practical guidance for public health led to a more than 2-fold difference in life ex- or even lock away individuals.”4(p42) These
professionals and to highlight the defining val- pectancy between upper and lower classes. various public health tools and functions,
ues of public health, values that differ in Also in the 1800s, Lemuel Shattuck, in Mass- while together successful in decreasing mor-
morally relevant ways from values that define achusetts, implemented the first system of bidity and mortality, nonetheless raise ques-
1776 | Public Health Matters | Peer Reviewed | Kass American Journal of Public Health | November 2001, Vol 91, No. 11
, PUBLIC HEALTH MATTERS
tions of ethics in terms of the means by which viously, was now given preeminent moral We live in a morally pluralistic society, and
these successes are achieved. status.8–10 Informed consent, a practical ap- it is inevitable that moral appeals will conflict
plication of the autonomy principle, became when attempts are made to determine appro-
BIOETHICS AND PUBLIC HEALTH a hallmark of the new bioethics, and codes priate public policy. A framework for public
of ethics for clinical practice, while still em- health ethics will help public health profes-
Bioethics helps health professionals and phasizing the need not to harm the patient, sionals recognize the multiple and varied
public policymakers recognize moral dilem- added clauses requiring physicians to “best moral issues in their work and consider
mas in health care and biomedical research care for the dignity of man in patients or re- means of responding to them.
and provides principles and moral rules with search subjects.”11(p21)
which to navigate through these dilemmas. (A That contemporary medical ethics or re- AN ETHICS FRAMEWORK FOR
framework of bioethics based on principles, search codes have made the right to noninter- PUBLIC HEALTH
as put forward by Beauchamp and Childress,5 ference central is understandable, given the
will be used here. However, there are many context out of which they emerged. That pub- A 6-step framework is proposed for consid-
other bioethical frameworks, including, for ex- lic health practitioners, lacking guidelines of eration. Components of this framework were
ample, ethics of care, casuistry, and virtue- their own, must turn to these same codes for proposed in an earlier article,15 and a similar
based ethics.) professional moral direction, however, is framework was proposed for public health
Dating to the 1960s and 1970s, bioethics more problematic. In rare instances, existing and human rights by Gostin and Lazzarini.16
grew out of questions of fairness in resource medical or research codes do discuss tradi- This is not a code of professional ethics,
allocation, moral issues raised by new tech- tional public health functions, such as breach- which more likely would address general
nologies, and a lack of oversight in human- ing patient confidentiality to report diseases norms and expectations of professional be-
subjects research. The public was swept up to the state.12 In such instances, however, the havior and probably would be the product of
in debate about whether the first artificial physician’s behavior is presented as an allow- a professional society. Rather, this is an ana-
kidney center should allocate scarce re- able exception to usual ethics rules in the lytic tool, designed to help public health pro-
sources on the basis of social criteria and name of public health. fessionals consider the ethics implications of
whether Karen Ann Quinlan should be kept At best, this leaves public health profes- proposed interventions, policy proposals, re-
alive artificially when she had no meaningful sionals needing to muddle through most search initiatives, and programs.
cognition. other situations on their own; at worst, it
In 1969, the Institute of Society, Ethics, could lead them, or even the public, to as- 1. What are the public health goals of
and the Life Sciences (now the Hastings Cen- sume that public health is the branch of the proposed program?
ter) was created to address questions of health care sanctioned by bioethics to make The first step for any proposed public
bioethics and to provide frameworks with exceptions to existing ethics rules at will, in health program is to identify the program’s
which to analyze contemporary moral dilem- the name of public health and safety. In- goals. These goals generally ought to be ex-
mas in medicine and science.6 In 1974, after deed, it is in great part because such power pressed in terms of public health improve-
several reports of US government–sponsored is vested in public health by law that a code ment, that is, in terms of reduction of mor-
research that compromised the rights and or framework of ethics designed specifically bidity or mortality. For example, an HIV
welfare of study subjects, a new national com- for public health is so very important. The screening program should have as its ulti-
mission issued the Belmont Report, which in- need for a code of ethics for public health, mate goal fewer incident cases of HIV, not
cluded ethics principles to guide the conduct then, might be viewed as a code of re- simply that a certain proportion of individu-
of human subjects research—beneficence, re- straint, a code to preserve fairly and appro- als will agree to be tested. A health education
spect for persons, and justice.7 Early framers priately the negative rights of citizens to program in cardiac risk reduction should
of bioethics elaborated on these principles noninterference. have as its ultimate goal (or the ultimate goal
and provided examples of how they were use- A code or framework of public health of a larger program of which it is a part) that
ful in analyzing dilemmas from other areas of ethics must emphasize positive rights as well, individuals will have fewer heart attacks, not
health care, not just research.5 however. Public health has affirmative obli- simply that individuals will learn new infor-
These early framers argued that, a priori, gations to improve the public’s health and, mation or even that they will change their
no principle ought to have moral superiority arguably, to reduce certain social inequities. behavior. A research study should have as its
over any other. At the same time, the issues A code of public health ethics is needed to ultimate goal (or the ultimate goal of a larger
that animated bioethics in the early years— address such social justice functions of pub- trajectory of which it is a part) that findings,
the need to tell patients and research sub- lic health. While frameworks have been put if positive, will be implemented with the tar-
jects the truth, the patient’s right to refuse forward in medicine to help clinicians think get population and improve its health status.
care or research participation—were ones in through the ethical issues in a clinical While more proximate and process goals
which the principle of respect for autonomy, case,13,14 no analogous framework is avail- (such as whether individuals will learn
perhaps given too little moral attention pre- able for public health practitioners. health information or whether they will
American Journal of Public Health | November 2001, Vol 91, No. 11 Kass | Peer Reviewed | Public Health Matters | 1777
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