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Public Health Ethics NOTE: The UW Dept. of Bioethics & Humanities is in the process of updating all Ethics in Medicine articles for attentiveness to the issues of equity, diversity, and inclusion. Please check back soon for updates! Author: Erika Blacksher, PhD, Affiliate Faculty, UW Dept. of Bioethics & Humanities Topics addressed:
This article provides a brief overview of various definitions and activities of public health, normative concepts and principles integral to public health, and an introduction to several substantive ethical questions and tensions central to public health ethics. The core of public health ethics concerns the moral justification of policies, programs, and the law to protect and promote public health. Because public health encompasses broad social programs and public policies, such as the provision of clean fluoridated water and bans on public smoking, questions regarding the justification of paternalistic interventions, fair distribution of health, and responsibility for health are prominent. Discrete patient care interventions (e.g., vaccinations) also contribute to public health, and difficult ethical questions can arise for health care practitioners. This article will provide some general guidance for health care providers. A list of references and other resources for public health can be found at the end of this article. What is public health? There is no settled account or definition of public health. It has been defined numerous ways, reflecting the diverse contexts, activities, and interventions of public health. A sampling of definitions, from general to more specific, include:
What are social determinants of health? Since its inception, public health has recognized social conditions as basic causes of illness and disease. Upon investigating and reporting on the causes of typhus in 1848, public health pioneer Rudolf Virchow linked famine and poverty with the oppression of Polish peasants and argued that the “elimination of social inequality was the only way to prevent typhus epidemics in the future” (Mackenbach 2009). The late twentieth century has witnessed renewed interest in social determinants as root causes of significant and widening disparities in health-both within and between countries (Commission on the Social Determinants of Health, 2008). In the United States, disparities in life expectancy have worsened for men and women since 1980 (Marmot, Bell 2009), and examples of such disparities are often dramatic. For example, the gap in left expectancy between men in Washington D.C. and in suburban Maryland is 17 years (Marmot, Bell 2009). Such challenges in combination with the emergence and reemergence of infectious diseases in the late twentieth century (Armstrong et al. 1999) raise many complex ethical questions for international organizations, governments, communities, and individuals. While early ethical commentary focused on cases such as health promotion and HIV/AIDS (Wikler 1978; Pellegrino 1981; Bayer and Moreno 1986; Bayer 1993, 1989), systematic analyses of the ethical foundations and frameworks of public health are much more recent. A journal dedicated to the topic-Public Health Ethics-was not established until 2008. What is Public Health Ethics? As with the concept of public health, there is no settled account of the moral concepts and methods of public health ethics. Systematic efforts to articulate ethical principles and frameworks to guide ethical inquiry in public health (Kass 2001; Childress et al 2002; Roberts, Reich 2002; Upshur 2002; Powers, Faden 2006;The Nuffield Bioethics Council 2007; Daniels 2008; Arras, Fenton 2009; Bernheim et al. 2013) identify a number of general moral considerations that include:
Much work needs to be done to translate these general ethical considerations or some subset of them into guiding principles and frameworks for public health policy and practice. Such work entails defining them, determining their scope, specifying criteria for resolving conflicts among them, and so on. Such efforts have produced frameworks of unranked principles (e.g., Nuffield Bioethics Council 2007), theories of social justice (Powers, Faden 2006), among other more practical approaches (e.g., Kass 2001). Such frameworks have counterparts in medical ethics, whose methods reflect a similar diversity (See Bioethics Tools). How does public health balance the interests of individuals with the interests of the broader public? Public health activities routinely bring some of these moral considerations into conflict. One major area of discourse and debate concerns the power of public health as an agent of the state to restrict individual choice in efforts to prevent disease and promote health. Many public health activities try to influence individual actions, though they may do so in more or less restrictive ways. Public health policy may eliminate choice altogether through, for example, compulsory quarantine of patients with infectious disease; restrict choice by, for example, banning smoking in public places or fluoridating public water supplies; guide choice through disincentives (e.g., taxes on health-harming goods, such as sugary beverages) and incentives (e.g., tax breaks on health-promoting goods); or inform choice through, for example, food labeling or media campaigns (Nuffield Bioethics Council, see chapter 3). The analysis of which of these actions are or are not ethically and politically justifiable is often informed by theharm principle, originally articulated by John Stuart Mill in his essay On Liberty. Mill argues “the only purpose for which power can be rightfully exercised over any member of a civilized community against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant” (Mill 1989). Mill qualifies the principle in several ways, for example, making exceptions for children and those cared for by others. But, in general the principle justifies state interference with individual liberty only when individual actions pose serious harm to others. The principle thus presupposes that behavior affecting only the self (“self-regarding behavior”) can be clearly distinguished from that affecting others (“other-regarding behavior”), which may be difficult in a public health context. Take, for example, the obesity epidemic in the United States, which has the highest rate among Organisation for Economic Cooperation and Development countries (OECD 2012). It has been argued that individual choices that contribute to overweight and obesity constitute an economic harm to others who share in the costs of the chooser’s health care (Pearson, Lieber 2009). Or, consider the dietary choices of an adult who is also a parent of small children. Parents’ meal planning, purchase of groceries, cooking, and direct feeding of a very young child has other-regarding, sometimes deleterious, consequences for children (Blacksher 2008). Such examples suggest that apparently self-regarding choices related to diet might be other-regarding in significant respects. Nonetheless, the distinction between self- and other-regarding behavior has been invoked persuasively in clear cases, for example, to justify the quarantine of individuals with infectious disease that can easily be transmitted or bans on smoking in public spaces to protect others from the harmful effects of second-hand smoke. What is paternalism and who is responsible for health? Cases where harm to others is absent or less easily established stir much more debate because they raise the specter of paternalism. Paternalism occurs when the state or an individual interferes with the preferences of a person for her own benefit (e.g., to promote her health) (Childress et al. 2002). Indeed, public health action often seeks to influence human behavior that arguably does no harm to others. Because chronic diseases now account for the majority of deaths, and personal behaviors make a nontrivial contribution to their onset and progression (McGinnis et al. 2002), much public health research and action seeks to change behaviors whose ill effects are felt primarily by those who engage in them. The least controversial tactics for promoting behavior change are educational in nature-providing people with information, whether it be the calorie content of foods, the health effects of certain behaviors, and so on. Educational campaigns are not coercive, as individuals can choose to heed them or not, and they can be argued to support more informed and thus autonomous citizens. Even Mill would likely have endorsed (non-controversial) public education campaigns for this reason (Nuffield Bioethics Council 2007). Educational strategies, however, often fail to produce behavior change, particularly among socially disadvantaged groups. Take obesity, which disproportionately affects minority and low socioeconomic groups. Education initiatives are most effective for individuals who have the time, interest, motivation, and resources to act on the information and opportunities made available. People who work long hours or double shifts, or who lack access to affordable gyms or safe spaces to walk or exercise, for example, may not have the time, energy, or financial resources to change habits that are embedded in ways of life. Thus, strategies based on education, information, and individual choice can reproduce or even exacerbate health disparities between more and less advantaged groups (Link, Phelan 1995; Link 2008). To address this challenge, social and material conditions may be remade to support health and healthy choices. In the case of obesity, such measures might include regulating food production (e.g., government choices about which foods to subsidize, banning excess sodium in processed foods), prohibiting the sale of soda and other sugary beverages in schools, and planning communities that will promote walking, recreation, and otherwise positive social connections. This structural approach to public health is, however, often criticized in political contexts such as the United States, where personal responsibility (for health and other goods) and individualism are highly valued. Debate over responsibility for health is not new (Reiser 1985) but it has intensified in the last few decades. One prominent way this debate has played out in U.S. health policy is the increased use of incentives and disincentives to promote the adoption of health-enhancing behaviors in both the private and public sectors. Private employers and state governments have ramped up their wellness programs, offering employees a variety of goods to participate in health screenings, on-site exercise programs, among other activities. While most programs use rewards in some form, the use of penalties is also on the upswing. A high-profile and much criticized example is West Virginia’s Medicaid program, which now requires beneficiaries to sign a personal responsibility agreement in order to receive an “enhanced” package of services (Blacksher 2008). Critics oppose such programs on numerous grounds. One common refrain is that penalties ‘blame the victim’. Responsibility lies not with these individuals, critics charge, but rather with social institutions and society at large. This claim of social responsibility for health is a critical plank in a larger argument that health (and/or the social determinants thereof) should be subject to considerations of social justice. Agents of public health often claim that health inequalities associated with social class, race, and ethnicity constitute a social injustice because they are caused, at least in part, by socially controllable factors. As Wikler points out, “The locus of blame is key, for if blame is placed on the individual, social structure is exculpated, and the resulting suffering and premature death will not be counted as a social injustice” (Wikler 2006). What constitutes a fair distribution of health? Systematic analyses of social justice and health equity are relatively recent (Marchand et al. 1998; Powers, Faden 2006; Asada 2007; Daniels 2008). Such analyses have taken up a number of basic questions, including: Are social inequalities in health unjust? Which inequalities are most urgent? What constitutes a fair distribution of health? A fundamental question concerns the place of social justice as an ethical construct in public health. Is social justice the moral foundation of public health? This view has its defenders (Powers, Faden 2006; Robertson 1998); however, it has not been a standard view. Rather, it is widely assumed that public health and health policy should aim to produce the most health benefits, or aggregate health, in a population (Brock 2000). Similarly, it has been suggested that maximizing benefits and removing harms “provide a prima facie warrant for many activities in pursuit of the goal of public health” (Childress et al. 2002). This utilitarian goal, which aims to maximize aggregate health, is distinct from the distributive goal to produce a fair distribution of health. Although public health activities and health policies may produce more health and reduce health inequalities, health initiatives very often reproduce or exacerbate disparities because, as already noted, better off people tend to benefit sooner and disproportionately from many health promotion interventions (Mechanic 2002; Frohlich 2008). One common strategy to address this problem is implementing interventions that target vulnerable subgroups. Such targeting may take a variety of forms, such as focused media campaigns, cash stipends, and social and health care services. But targeting also carries an ethical risk-the further marginalization and stigmatization of minority and socio-economically marginalized groups. As commentators have noted, the pursuit of social justice entails not only distributive goals, such as reducing health disparities, but also recognition goals (Fraser 2003, Young 1990, Anderson 1999). This demand of justice has been variously described but generally refers to a form of basic respect for persons that, at the very least, protects non-dominant groups from discrimination and marginalization based on group membership, such as race, ethnicity, gender, sexual orientation, nationality, social class, and so on. Racism and sexism are paradigmatic examples of transgression of basic respect in this sense. Recognition may be further elaborated to include the idea that all persons have an equal opportunity to participate as peers in public life and to have a voice in important public issues, particularly those that directly affect them (Fraser 2003, Anderson 1999). What is participation in health? Recognition in this sense lends ethical support to a core value of public health-the notion of participation in health. Participation has long been a basic principle of public health practice and an essential component of health equity (Commission on the Social Determinants of Health 2008). Participation in health is variously defined but generally the idea refers to a collaborative process that equitably engages community members, organizational representatives, researchers, among others in knowledge creation and social change (Rifkin 1986; Robertson, Minkler 1994; Wallerstein, Bernstein 1994; Israel et al. 1998). Participatory processes are defended on grounds that the research and action that result will be more effective, fulfill an obligation of procedural justice, and produce more equitable outcomes (Wallerstein, Duran 2010; Dankwa-Mullen et al. 2010; Wallerstein 2006; Daniels, Sabin 1998). They may also protect non-dominant communities from health interventions that further marginalize and stigmatize them (Blacksher 2012) and may go some distance in cultivating trust between research institutions and community partners (Yarborough et al. 2012). ETHICAL QUESTIONS FOR INDIVIDUAL PRACTITIONERS
Case 1 below discusses this question in the context of a patient with sexually transmitted disease. References
Additional Readings: Public Health Ethics
CASE STUDIESPublic Health Ethics: Case 1Sexually Transmitted Diseases and Contact Tracing MG is a 27-year-old graduate student, recently married, who comes into the student health clinic for a routine pelvic exam and Pap smear. During the course of the exam, the gynecology resident performing the exam obtains the Pap smear, but also obtains cervical cultures for gonorrhea and chlamydia. The examination concludes uneventfully. Several weeks later, MG receives a postcard indicating that the Pap smear was normal, with no evidence of dysplasia, but that the cervical culture for gonorrhea was positive. The card instructs her to come into the clinic to discuss treatment, and that "public health authorities" have been notified for contact tracing, which refers to the identification and diagnosis of sexual partners, as required by law. The young woman is terrified that her husband will be contacted. Is contact tracing ethically justified? Case Discussion Yes. Her sexual partners have a right to know that they were exposed to gonorrhea. Notification has positive public health benefits that outweigh the young woman’s concerns about violation of privacy. First, those notified can be tested and treated. Second, they can take precautions to protect others from contracting gonorrhea (like using condoms). Third, their sexual partners can be notified to further reduce the spread of infection. To address the young woman’s concerns, she can seek advice from her doctor and public health officials and may choose to tell her husband herself. Should she fail to inform her husband, public health officials will be obligated to do so. Public Health Ethics: Case 2
Forced Treatment for Multidrug-Resistant Tuberculosis MW is a 33-year-old man with multidrug-resistant tuberculosis (MDR-TB). He is homeless, and has a pattern of missing many of his scheduled clinic visits. Upon starting a multi-drug regimen for his condition, MW initially comes to his scheduled clinic visits, but after a few weeks begins missing them. The provider contacts the social work case manager, who arranges supervised drug administration (also known as “directly observed therapy”). Nevertheless, MW often cannot be found and this approach is deemed to be failing. Should MW be forced into treatment against his will? Case Discussion This is a case in which the health of the public is clearly and seriously threatened. Multidrug-resistant tuberculosis has the potential of causing substantial morbidity and mortality for the population, particularly in large urban areas. Thus the need for the individual patient to be treated for the good of the public is high. Similarly, the patient himself stands to benefit from the treatment. Ordinarily, patients have the right to refuse potentially beneficial treatment, provided they are competent and make an informed decision to do so. The tension created in this case is that the patient's refusal to follow the medication regimen puts others at substantial risk of harm. Hence it may be justifiable to compromise his autonomy to protect the health of others. In such cases, every effort should be exhausted to enlist the patient's cooperation with the medical regimen. Interventions such as directly observed therapy are often effective ways to achieve the desired result without compromising the patient's autonomy. Failing this, it would be justifiable to seek court permission to confine and treat the patient against his will. In the legal process that ensues, considerations will include the magnitude of harm, the degree to which
specific individuals are exposed to harm, and the probability of harm. Public Health Ethics: Case 3Health Care Disparities and Priority for Treatment Samuel Banks is a 54-year-old accountant with a college degree and health insurance. He was the first of four children and a first generation college graduate. Having worked hard all of his life, Mr. Banks has been exposed to a variety of chronic stresses, including racism. As an African American growing up in the southeast United States, Mr. Banks was exposed to a steady stream of slights and insults as well as institutional forms of racism. Despite these challenges, he had been healthy much of his life even though he put on an extra 25 pounds in his late 40s. Over this past year he began to have heart issues. Initially, he thought he was just having heartburn, but the discomfort persisted. Mr. Banks visited his physician, who was new to him because his employer had just switched insurers. He had waited an hour in the waiting room and was agitated by the time he got to see Dr. Susan Mott. The visit did not last long. Dr. Mott was polite but hurried, facing a full waiting room of patients, and Mr. Banks perceived the doctor as rushed and rude. He left Dr. Mott’s office frustrated and determined to find a new physician. Before he could find one, he had a heart attack. He was rushed to the emergency room where he received medical treatment that included a physical exam, ECG, chewable aspirin, supplemental oxygen, nitroglycerin, and monitoring through the night. What he needed and did not receive, however, was coronary artery bypass graft surgery (CABG). This is not an uncommon experience for minorities. Members of racial and ethnic groups receive less and lower quality health care than their white counterparts. The Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care documents the extent of these disparities in health care and their potential sources (Geiger HJ et al. 2003). Many people argue that health care disparities constitute an injustice. The argument can be made on a number of moral grounds, including the idea that people should be treated equally, regardless of race or ethnicity, receiving treatment only on the basis of medical need. Some commentators, however, have raised the question of whether disadvantaged patients should be given priority at the point of care. Should the
health care system prioritize care for members of disadvantaged groups over that of other patients? Case Discussion These allocation questions have received scant attention in bioethics, despite considerable attention to other resource allocation problems (Daniels 1994). There are arguments for and against giving priority to socially disadvantaged patients at the point of treatment. Some of the reasons in support of prioritizing members of socially disadvantaged groups include the view that it would constitute a form of compensation for the unjust disadvantages, including poor health, that poor and minority groups suffer, and, in doing so, promote social cohesion; and that better off groups are to some degree responsible for the conditions of worst off groups, given their contribution to the institutions and policies that unfairly distribute the social determinants (Hurst 2009). Reasons against priority include the view widely held in medicine that social attributes should not be taken into consideration within medicine, that everyone should be treated equally, based only on medical need, and that doing otherwise would demonstrate disregard and disrespect for the needs of those who are better off; and that such a practice would alienate more powerful and privileged groups and risk strong support for health system funding. Another important consideration is that disparities in health should be addressed at their source, which many locate in the non-medical determinants of health (Williams et al. 2008). Public Health Ethics: Case 4Childhood Obesity and Parental Responsibility Joe lives with his mother and aunt and her two children, both under age 6, in a small duplex south of Seattle. Average height for his age, Joe is 9 years old and weighs 184 pounds. His two cousins are not obese, but they are overweight. The mothers of the family work a number of jobs to make ends meet. They do not have much money for material things or extra curricular activities, and increasing gang activity in the area has made them reluctant to let the children play on their own in the nearby park and soccer field. What the family does not do in the way of ‘fun’, they make up for with food. The school nurse has brought Joe’s obesity to his mother’s attention twice, each time suggesting several approaches to helping him lose weight. They include buying healthier foods and healthier cooking. Joe’s mom has been slow to take up these practices because the foods are more expensive than what she usually buys, the recipes seem strange to her, and she suspects they will not taste very good to Joe or her niece and nephew, who she often also cooks for. At a recent pediatric check up Joe’s physician cautions the mother that she really needs to get Joe’s weight under control. He is developing elevated blood sugar and has experienced difficulty breathing in his sleep. If she does not take action, he says he might be obligated to alert child protective services. As childhood obesity has become an epidemic problem in the United States, such cases increasingly are being reported. The rate of childhood obesity has more than tripled in the last three decades with serious short- and long-term health consequences. Obese children are significantly more likely to experience a wide range of poor health outcomes, including type II diabetes, cardiovascular conditions, asthma, sleep disordered breathing, anomalies in foot structure, low self-esteem, depression, and high-risk behaviors. Studies suggest that as many as half of all obese children remain obese as adults, leading to further health risks-elevated risk of heart disease, stroke, diabetes, osteoporosis, lower-body disability, some types of cancer, and premature mortality in general. Public health leaders emphasize structural and environmental interventions to remedy the U.S. obesity epidemic, but even they acknowledge the role parents play in contributing to children’s healthfulness, including normal weight (Frieden et al. 2010). Increasingly, state intervention in severe cases of childhood obesity is being called for under certain circumstances (Murtagh, Ludwig 2011). Are clinicians obligated to report parents of obese children to child protective services? Case Discussion Although parents have significant discretion to rear their children according to their own values and practices, society may justifiably intervene when it deems parental behaviors expose their children to serious harm. This “harm principle,” discussed above, is often appealed to as the basis for intervention (Murtagh, Ludwig2011). There have been legal cases in which a child has been removed from the home in cases where parental practices are judged to have contributed severe morbid obesity, in states that include California, Indiana, Iowa, New Mexico, and New York. Similar cases have also been reported in the United Kingdom. Commentators on the subject, however, urge caution, as removing a child from the home can seriously harm a child in other ways (Black et al. 2011). Commentators encourage using intermediate options, such as in home support services, parent training, and financial assistance, and seeking a second medical opinion before any action is taken. What is an example of public health ethics?Examples include the principles of respect for autonomy, beneficence, nonmaleficence, and justice. Some accounts of ethics in public health have pointed to additional principles related to social and environmental concerns, such as the precautionary principle and principles of solidarity or social cohesion.
What are some examples of ethical decision making in healthcare?An example of ethical decision-making in healthcare includes choosing between patient autonomy and beneficence. Another example is choosing between being honest to the patient and withholding information that the patient's close family might have requested.
What are some ethical considerations that should be taken into account in the context of public policy?[6] Here, five ethical principles are introduced: integrity, competence, responsibility, respect, and concern.
What are the ethical considerations involved in decision making process?Ethical decision-making is based on core character values like trustworthiness, respect, responsibility, fairness, caring, and good citizenship. Ethical decisions generate ethical behaviors and provide a foundation for good business practices.
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Examples of how public health professionals can apply ethical considerations in the planning process
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