the graying of america: challenges and controversies • spring 2012 85
Introduction For over 100 years, the field of contemporary public health has existed to improve the health of commu- nities and populations. As public health practitioners conduct their work — be it focused on preventing transmission of infectious diseases, or prevention of injury, or prevention of and cures for chronic condi- tions — ethical dimensions arise. Borrowing heavily from the ethical tools developed for research ethics and bioethics, the nascent field of public health ethics soon began to feel the limits of the clinical model and began creating different frameworks to guide its ethical chal- lenges. Several public health ethics frameworks have been introduced since the late 1990s, ranging from extensions of principle-based models to human rights and social justice perspectives to those based on politi- cal philosophy. None has coalesced as the framework of choice in the discipline of public health. This paper examines several of the most-known frameworks of public health ethics for their common theoretical underpinnings and values, and suggests next steps toward the formulation of a single framework.
The Evolution of Public Health Ethics It is impossible to read a paper about public health ethics without seeing the now familiar dilemma that traditional theories of clinical and bioethics are not transferrable directly to public health ethics. The major difficulties in translation stem from the funda- mental differences between clinical and public health
practice. Most saliently, clinical medicine has at its core the patient-provider relationship, while public health has at its core the responsibility for the health of the community. Clinicians see patients they know; public health practitioners intervene upon popula- tions of unspecified individuals.1
Other important differences exist between clini- cal and public health practice. Clinical medicine uses medical interventions to cure or treat existing illness, while public health practice uses primarily non-med- ical means (with the notable exception of immuni- zation) such as policy and law, sanitation, the built environment, and behavioral health to prevent injury and disease and to promote health and wellness.2 In clinical medicine, a limited number of similarly clini- cally trained professions (e.g., physicians and nurses) deliver direct care, whereas in public health practice an increasingly diverse group of practitioners round out the effective team, including epidemiologists, stat- isticians, laboratorians, physicians, informaticians, economists, decision and behavioral scientists, and policymakers.3 This team produces what Marcel Ver- weij and Angus Dawson4 describe as a collective effort, usually via government, to bring about participation of the public. Both clinical and public health practice attend to justice, but the focus of justice in clinical medicine is usually faint and on distributive justice, or ensuring that there is enough for everyone entitled to care. In public health practice, the focus on justice emphasizes social justice,5 or rights to health care, and disparities in access and outcomes.
These characteristics differentiating clinical and public health practice lead to different ethical chal- lenges and presumptions in the respective fields. The moral governance needed for public health did not translate directly from the principles of bioethics, as
Public Health Ethics Theory: Review and Path to Convergence Lisa M. Lee
Lisa M. Lee, Ph.D., M.S., serves as Chief Science Officer in the Office of Surveillance, Epidemiology, and Laboratory Ser- vices at the U.S. Centers for Disease Control and Prevention. She received a Ph.D. from Johns Hopkins University in Balti- more, Maryland and an M.S. from the Alden March Bioethics Institute at Albany Medical College in Albany, New York.
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transmuted for research ethics in the 1940s and 1950s or clinical ethics in the 1960s and 1970s. In the 1980s, the early HIV/AIDS epidemic elucidated the inad- equacy of clinical ethics to address pressing ethical challenges that straddled private and public life. This inadequacy led pioneering theorists such as Ronald Bayer et al.,6 Ruth Faden and Nancy Kass,7 and Law-
rence Gostin and William Curran8 to discuss ways to expand bioethics in the 1980s to include public health ethical concerns. In 1988, Dan Beauchamp9 foreshad- owed the 2000s by bringing together health, equity, political philosophy, and democratic theory to root public health ethics as a balance of, as opposed to a struggle between, individual freedom and community well-being. Recognizing the broader need, scholars and public health practitioners began to put forward a variety of specific suggestions for ethical frameworks for public health in the 1990s.
To discuss the ethical framework of public health, it is critical to understand exactly what public health encompasses. Public health was defined by the Insti- tute of Medicine in its landmark 1988 publication, The Future of Public Health,10 as “what we, as a society, do collectively to assure the conditions in which people can be healthy.” A more delimited definition was prof- fered by John Last in the The Dictionary of Public Health,11 stating, “Public health is an organized activ- ity of society to promote, protect, improve, and, when necessary, restore the health of individuals, specified groups, or the entire population.” The American Public Health Association outlined the 10 essential functions of public health deemed necessary for effective perfor- mance (see Table 1).12 With such broad conceptions of the field, it is not surprising that many approaches and theories for public health ethics have developed over the past decade and a half.
Some have suggested a complete departure from the clinical ethics approach, while others suggested bor- rowing heavily on the longstanding successful biomed- ical model. The field of public health ethics continues to grow with an increasing number of publications on
the topic, a widening array of ideas of how to deal with the unique ethical needs and features of public health practice, and the founding of journals devoted to the topic of public health ethics (quite separate from bio- ethics) where these ideas can be exchanged in the peer reviewed literature. Developers of public health ethics frameworks have outlined the need for models sepa-
rate from bioethics. Interestingly, new developments in bioethics have called for incorporating principles of public health ethics, especially those that recognize the health needs of the population;13 the merit of plu- ralistic values such as equity, reciprocity, and the com- mon good;14 and evidence-based decision-making.15
The Basics of Bioethics Contemporary biomedical ethics, or bioethics, operates in large part by the practical application of four princi- ples considered in the relationship between the health care provider and the individual patient. These four principles — autonomy, beneficence, nonmaleficence, and justice — were outlined by Tom Beauchamp and James Childress16 in the 1970s. Although not without critics,17 this “principles approach” remains the main- stay of hospital ethics committees worldwide. Clinical bioethicists consider these principles to have prima facie status, which describes an obligation that is to be fulfilled unless it conflicts with an equal or stronger obligation. Clinicians must identify the relevant prin- ciples, weigh them against the concerns of a case, and justify their clinical decisions and recommendations based on the totality of the weighted principles vis-a- vis the best interest of the patient.
During the latter half of the 20th century, autonomy became and remains the supreme value in clinical care in the United States and in much of the developed world. Beneficence, or the set of actions intended to benefit others, lost its primacy, and providers were forced to open their previously unquestioned goodwill to the scrutiny (and sometimes challenge) of inter- ested patients.18 It was no longer enough for a physi- cian to provide a set of instructions, say to take a medi-
In 1988, Dan Beauchamp foreshadowed the 2000s by bringing together health, equity, political philosophy, and democratic theory to root public health ethics as a balance of, as opposed to a struggle between, individual
freedom and community well-being. Recognizing the broader need, scholars and public health practitioners began to put forward a variety of specific
suggestions for ethical frameworks for public health in the 1990s.
the graying of america: challenges and controversies • spring 2012 87
Lisa M. Lee
cation and rest, based on what he felt was best based on years of training and experience (beneficence). Patients wanted to know what the medication was, its risks, if it was the only option, what other treatment alternatives there were, and often had suggestions of their own (autonomy). The perception of autonomy as the prevailing principle rose from the convergence of a number of changes in the social and medical milieu,19 but ethical theory continues to hold it in prima facie equivalence with beneficence, nonmaleficence, and justice.20
A Review of Selected Suggested Frameworks for Public Health Ethics Here, 13 public health ethics frameworks are reviewed (see Table 2). These were selected due to their promi- nence in the field, impact on the development of other theories, or novelty in approach. For purposes of this paper, I have divided them into two categories: (1) those frameworks that are practice-based, or appear to have developed from the observations of the needs of public health practitioners and that cite few or a mix of philosophical bases; and (2) those that are theory-based, or appear to have grown from a specific philosophy, ethical or otherwise, and attempt to stay true to that philosophy in applying the framework to public health practice, science, and decision-making. I have outlined three specific characteristics of each framework. First, where applicable, I outline the theo- retical underpinnings that drive the framework. For the practice-based frameworks, these underpinnings might be drawn from several (or no) schools of ethical thought. For the theory-based frameworks, there is at least (and usually) one philosophical approach. Sec- ond, I examine the underlying assumptions, beliefs, or perspectives upon which the framework is built; I call
these the foundational values of the framework. Third, I outline the expectations or actions of the framework — what it is designed to help public health practitio- ners do. I call these the operating principles of the framework. These three ideas might be labeled some- thing other than underpinnings, values, and operat- ing principles in the original frameworks, but note the definition of the terms here. Upon review of the primary frameworks available to date, I will examine the similarities and gaps in values and principles and analyze whether the field is close enough in its think- ing to move toward a convergent approach.
Practice-Based Frameworks Practice-based frameworks for public health ethics emerged from the observation that ethical frameworks used in clinical settings were inadequate for resolving ethical dilemmas faced by public health practitioners. Stemming primarily from principle-based bioethics frameworks, these approaches outline foundational values and provide operating principles that direct a course of thoughtful action (or series of considerations) for practitioners faced with ethical quandaries in the public health sphere. Practice-based frameworks do not attempt to provide a comprehensive philosophi- cal approach; however, they do derive in part from implicit or explicit normative perspectives.
One of the American pioneers of thinking about public health ethics as a discipline separate from bio- ethics or research ethics is Nancy Kass of Johns Hop- kins University. She wrote one of the earliest suggested ethical frameworks for public health, published in the American Journal of Public Health in 2001.21 For the first time, a framework that focused on the practical nature of public health was outlined in a practitioner’s journal, aimed at public health professionals rather
Table 1 American Public Health Association, “10 Essential Public Health Services,” 2010, reprinted from <http://www.apha.org/programs/standards/performancestandardsprogram/ resexxentialservices.htm> (last visited January 10, 2012).
1. Monitor health status to identify community health problems. 2. Diagnose and investigate health problems and health hazards in the community. 3. Inform, educate, and empower people about health issues. 4. Mobilize community partnerships to identify and solve health problems. 5. Develop policies and plans that support individual and community health efforts. 6. Enforce laws and regulations that protect health and ensure safety. 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. 8. Assure a competent public health and personal healthcare workforce. 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
10. Research for new insights and innovative solutions to health problems.
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than philosophers. Kass, like others before and after her, discussed the inadequacy of the bioethics model to support the needs of public health ethics and pro- posed a framework (see Table 2) based on two key val- ues — rights (both negative and positive) and social justice. She described several principles supporting what she termed “a code of restraint” balanced with the “affirmative obligation to improve the public’s health” and reduce health inequities. The key princi- ples in the framework include ensuring the minimal level of interference to improve population health in order to preserve the negative rights of the citizenry, identifying and minimizing harms and burdens to the maximum extent possible while not greatly reducing program effectiveness, reducing social inequities and health disparities, and providing evidence of program benefits. Kass was one of the first to urge public health practitioners to engage in thoughtful ethical analysis using the framework in order to make us “meticulous in our reasoning, requiring us to advocate interven- tions on the basis of facts and not merely belief.”
James Childress et al. (including Kass), attempted to conceptualize the terrain of public health ethics as it existed in 2002.22 The authors outlined the quintes- sential problem for population medicine as it relates to clinical medicine. Three concepts of “public” under- gird their belief that the bioethical model is a poor fit for public health ethics: the meaning of “public” as population; the execution of “public” health as an inherently governmental activity that must be well- rooted in moral reasoning expected by the public that the government represents; and third, the definition of “public” in its broadest sense to include all social action, both public and private, that affects health. The authors outlined three goals of public health, including production of benefits, prevention of harms, and maximization of utility. The general ethical and moral considerations for achieving these goals, they state, “[do] not entail a commitment to any particu- lar theory or method. What we describe and propose is compatible with several approaches.” They list the following relevant moral considerations for deliberat- ing about and justifying public health actions. Public health agents must produce benefits and prevent and remove harms. They must produce the best possible utility, that is, the optimal balance of benefits over harms. They must ensure fair distribution of bur- dens and benefits, ensure the public’s participation, and respect autonomy in choice and action. They must protect individual privacy and confidentiality, and keep promises. They must be transparent, that is, speak truthfully, and disclose information. Finally, they must build and maintain public trust. All of
these values are considered prima facie and when one appears to become more important than another, the authors offer five conditions to be used to justify over- riding one or more of the moral considerations.
In the same year, Ross Upshur, a Canadian physi- cian, performed a literature review and reported the principles relevant to the ethical justification for pub- lic health interventions published to date.23 Upshur began by pointing out the substantive differences between clinical and public health practice, includ- ing the locus of “care” as the state versus the clinician, the focus on the community or population versus the individual, the lack of an analogous fiduciary role as that played by physicians, and the fact that popula- tions are diverse and require pluralistic approaches to problem solving. He argued that a set of principles for public health professionals might be useful as they reflect on ethical issues, as the principles are heuristic in nature and serve to bring clarity to a broad range of decisions required in public health practice. These principles, he argued, would not represent a full artic- ulation of a theory for public health ethics, rather they would relate to whether or when a particular public health action is justified. The principles are based on empirical observations of the needs of public health practitioners and their decision-making via a litera- ture review. Upshur did not make explicit the under- lying values of the principles, but within the descrip- tion of each he intimates the importance of autonomy, nondiscrimination/social justice, social duty, honesty, and truthfulness. The four principles Upshur found in the literature in the early 2000s included the harm principle, the principle of least restrictive or coercive means, the reciprocity principle, and the transparency principle. The harm principle, stemming from the phi- losopher John Stuart Mill, was described by Upshur as the foundational principle and dictates that the only justification for imposing power over an individual member of society against his will is to prevent harm to others. The principle of least restrictive or coercive means dictates that despite the availability of a variety of methods to reach a public health goal, the first used must be that which restricts personal liberty the least. The reciprocity principle states that there is an obliga- tion on the part of the public to comply with public health requests once they are warranted and an ethical decision for action has been made. Finally, the trans- parency principle requires stakeholder involvement in decision-making, as well as a clear and account- able process that is free of diversion by groups or per- sons with interfering special interests. Upshur called for integration of ethical reasoning into public health