Chapter 7 Ethics and public health

After reading this chapter you should be able to:

recognise that ‘ethics’ is often defined and approached in different ways

describe the foundations and development of public health ethics

summarise some key ethical systems and their relevance to public health practice

outline and critique some codes of ethics, and discuss their application to public health practice

recognise, evaluate and communicate ethical concerns regarding public health, and apply ethical principles in your practice.

Introduction

While there has been a recent increase in dialogue on ethical practice in public health, the entire domain is still very much a work in progress and, in comparison to other fields, somewhat underdeveloped. This deficiency is critical, not only for the public health practitioners and their client populations, but also when politicians, law-makers and policy-makers look to public health professionals for guidance on important health-related issues. For example, as human populations continue to enter into a global monoculture, with its consequent increase in pandemic and epidemic risks, decision-makers need help from health professionals to grapple with difficult decisions arising from these. As public health ethics, and the corresponding obligations of health professionals, develop, health practitioners will need to keep up to date on how those changes impact on their own practice.

This chapter introduces you to the basic ethical principles that underpin public health practice. One of the pivotal challenges in public health ethics is balancing the rights of the individual with the wellbeing of the population as a whole. Using the example of an epidemic, a person with a contagious disease might have their right to liberty suspended to protect the rest of the population from exposure to that disease. How should we go about deciding when it is fair, reasonable or acceptable to restrict the rights of one category of people to ensure the wellbeing of others?

The questions posed in that example give some indication of the important issues of values, power and fairness that are engaged in public health ethics. The themes to be considered in this chapter include the characteristics of ‘ethics’, the advantages of reflecting on ethics and values, the foundations of public health ethics, and whether and how we can incorporate ethics into our practice. These themes will be illustrated by some potential ethical dilemmas in public health practice. And it will be argued that ethics is more than a ‘mere’ abstract philosophical concern; it is very much a practical field intimately tied up with effective service delivery to consumers, which is of great concern to health professionals, politicians and, not least, the public. It is not about being more ethical; there is already an implicit expectation from the public and health professions that health services, including public health, ‘be ethical’.

Public health employs a variety of methodologies, requires a range of knowledge and expertise and is affected by constant changes in technologies, legislation and culture (Fry et al. 2004). The beliefs and philosophies that guide practice among people working in a public health-related capacity focus on promoting the health of the population. But until fairly recently, most analyses of public health ethics have been concerned with research ethics and responses to infectious diseases (Kenny et al. 2006), such as quarantine and/or isolation for H1N1 influenza (Swine flu). However, public health ethics deals with more than these, emphasising population health, safety and wellbeing; impartiality in service delivery; and the rights of both individuals and groups (Gostin 2003).

Because most ethical analysis in other fields such as medicine and law has been about individual rights and responsibilities, it is challenging to make the transition from that individual focus to one that emphasises whole populations (Bayer et al. 2007). It is vital that the core concerns of ethics, including the ‘common good’ and the corresponding key functions of public health practice, are identified and explored (Kenny et al. 2006). Integrating these competing values is indispensable to a constructive ethical framework (Kenny et al. 2006) and a variety of ethical analyses are necessary in order to encapsulate the diversity and depth of public health (Bayer et al. 2007).

You may wonder what relevance ethics has to your own practice. Indeed, it is arguable that since the vast spending and work hours that go into public health initiatives and policies are, at root, ethically motivated (an intention to ‘do good’) public health practitioners are making explicit or implicit decisions on a frequent basis. In other words, regardless of your particular health-related discipline, all of your actions have ethical implications. Health professionals are regularly confronted by ethical dilemmas that call for careful consideration and decision-making, and deciding on the correct course of action is often challenging. For example, as well as yielding improvements in health, an intervention may cause harm; for instance, ‘justice’ may be violated by imposing more of a burden on one subpopulation than on the others. Understanding the risks will help you to practise more circumspectly (Fig. 7.1).

Fig. 7.1 ‘Integrity’.

What is your understanding of ‘ethics’? Does it have positive, negative or neutral connotations? Do you think your ethical perspective is influenced by other factors, such as your religious or cultural background? The activity on this page will help you to clarify some of these issues.

Activity

• Discuss with your classmates what ethics means to them and how they would define ‘ethical practice’. Ask them to imagine some instances of non-ethical conduct within their own particular professions.

Reflection

How do the perceptions of ethics collected from the people you surveyed accord with your own? Is there an all-embracing theme, one that incorporates all your views, or are there conflicts? Did anyone refer to the issue of religion or culture, and how do these factors relate to someone’s ethical beliefs? Do you think it is possible to work effectively with people whose ethics differ significantly from your own? How do your ethical perspectives influence your practice?

Since all health practitioners working in public health may be confronted with difficult choices regarding the range of possible options, they need to be familiar with an ethical framework that is in accord with current public health practice. Moreover, debates on various cultural, environmental, economic and political issues, which all have the potential to impact on health, regularly raise themes related to ethical and fair conduct, even though these issues may not be overtly identified. For example, with nationwide concerns over electricity production, it often seems that we are forced to choose between different types of pollution (see Chapter 11 for Environmental Health), such as airborne chemicals associated with coal-fired electricity production versus radioactive by-products from nuclear energy production, both of which raise significant public health issues. These include ethical questions, such as who should ‘shoulder the burden’ of these, and whether it is fair that people living near these industries may have higher health risks than the rest of the population?

Moreover, the ability to see the ethical dimension of a public health issue presents another compelling argument for exploring ethics in public health – you will be able to advocate for programmes and policies within other sectors that minimise the risks to population health.

This chapter does not attempt to give you specific instructions to cover every potential ethical dilemma; rather, it aims to raise your awareness of some of the ethical issues that are bound to confront you in your practice. Additionally, it seeks to provide you with insight regarding the ethical principles that are pertinent to a wide range of health professions and an appreciation of the range of perspectives, theories and approaches to any ethical issue.

The next section summarises some of the background to the study of ethics, so that you are familiar with the relevant concepts.

Ethical frameworks, theories and concepts

Questions and concerns about matters of ethics are so widespread throughout the many diverse fields of human behaviour and society that Ethics has long been one of the central fields of Philosophy. Accordingly, many of the key ideas, concepts and theories that are employed in public health ethics are derived from the philosophy of ethics. Therefore, a brief overview of ethics philosophy is essential for health practitioners who may be involved in potentially controversial public health-related decisions.

The discipline of ethics, in philosophy, typically enquires into a wide range of concerns: normative ethics tries to ascertain what are good or right actions and motives; applied ethics involves exploring and resolving particular dilemmas; descriptive ethics explores the ethics people actually believe in and/or put into practice and meta-ethics analyses the essential nature of ethical principles and whether they can be objectively validated.

Normative ethics in public health

Given its objective of finding out how to determine what are good and right actions and motives in practice, normative ethics has direct relevance to public health practice. Five of the most common normative ethical positions are outlined:

1 Consequences: Consequentialism claims that an action’s rightness depends on its consequences or outcomes (Cribb & Duncan 2002). One of the most familiar consequentialist theories is utilitarianism, which deems an action to be proper if it brings about the greatest amount of pleasure and the least amount of pain, for the maximum number of people.

2 Duties and Rights: Deontology maintains that every individual has absolute duties and rights – and these should form the basis of ethical decisions. That is, the consequences of actions do not determine their merit; rather, it is other elements (Beauchamp & Childress 2001), such as your intent. One such theory is Kant’s Categorical Imperative, which states that you should only carry out any action if you would accept that same action as a universal law.

3 Character: Virtue ethics gives emphasis to an individual’s intrinsic qualities (whatever people agree are desirable personal characteristics, for example bravery, compassion and honesty) in preference to rules or consequences.

4 Human Rights and Liberty: Liberalism’s focus is usually rights, equality, freedom and democracy. Such concepts, particularly ‘rights’ and the ‘right to health’, are the basic premise of many influential public health documents (Parker et al. 2007). For example, the Alma-Ata Declaration states that health ‘… is a fundamental human right …’ (WHO 1978).

5 Community: Communitarianism recognises humans as social beings, thus emphasising relationships and shared values (Sindall 2002). This perspective requires enforcing limits on individual autonomy for the benefit of the community (Callahan & Jennings 2002).

The following example applies each of these five viewpoints to demonstrate how different beliefs/theories in normative ethics have real-world practical impacts.

The time-honoured methods of preventing the spread of infection are quarantine and isolation. During the SARS (severe acute respiratory syndrome) pandemic (2002–2003), the World Health Organization’s (WHO) response was to concentrate on isolation and quarantine, as well as surveillance, contact-tracing and limiting travel (Gostin et al. 2007).

A consequentialist might argue that it is right to isolate someone with a highly lethal, infectious disease because of the consequences of not doing so – a probable epidemic, and subsequent deaths.

In contrast, someone arguing from a duty and rights viewpoint might claim that regardless of the possible outcomes, there is a duty to protect people, and everyone has a right to be protected from disease.

A virtue ethicist might defend isolation based on the good intentions of those enforcing isolation and quarantine.

Liberalists might argue against enforced isolation and quarantine, and make a case for education and persuasion to convince infectious people to keep away from other people.

Communitarians may argue that it is justifiable to limit individual freedoms, that is, isolating an infected person, if it benefits the whole community.

Clearly, there are many differences between these examples of normative ethics, for example, the divergence between the ‘good’ of the individual (liberalism) and that of the community (communitarianism). Nevertheless, they also have things in common; for example, utilitarianism and communitarianism both tend to favour the community over the individual.

Activity

• Discuss with your classmates how each of these five normative positions would apply to a different public health situation. Consider whether one of the five normative ethics positions is best or correct, or if it is more useful to use the five positions as complementary viewpoints that all have relevance, and require skilful balancing. Explore how the relevance of each of the five positions changes – depending on the specific public health situation it is being applied to.

Reflection

The usefulness of these various normative positions can only be realised if their relationships to each other are understood, just as ethics can only be grasped in terms of the relationships between people, groups and their total environment. That is, we cannot have ‘stand-alone’ definitions of these viewpoints, nor employ a one-size-fits-all approach. However, we need to agree upon the meanings of the ethical theories and approaches to help us to communicate in our efforts to apply ethics in public health endeavours. Arguably, the SARS example above illustrates that each of these normative ethical positions offers their own unique perspective on the ethics of any given public health action. Accordingly, the potential contribution of all the approaches outlined here should be considered when assessing the ethics of any given public health intervention, research or programme.

The next section examines some of the factors and controversies that have influenced the development of public health ethics.

Themes and debates in the development of ethics in public health

Some authors have differentiated between medical ethics and bioethics (Bayer et al. 2007; Beauchamp & Childress 2001; Thompson et al. 2003). ‘Medical ethics’ generally refers to a health professional’s ethical responsibility towards their (individual) patient. Although the category of ‘bioethics’ sometimes includes ‘medical ethics’, ‘bioethics’ has more typically encompassed such issues as research ethics, genetic research, genomics and cloning. Bioethics developed in the middle of the twentieth century as a discipline separate from medical ethics, and medical ethics’ emphasis on individual autonomy and the right not to be harmed (Bayer et al. 2007; Beauchamp & Childress 2001; Thompson et al. 2003).

Because bioethics has tended to concentrate on ethical questions relevant to clinical research and practice, it has usually emphasised the interests of individuals – largely patient autonomy (Azétsop & Rennie 2010; Thompson et al. 2003). This is not surprising, in view of the development of the discipline of bioethics as a reaction to some questionable research practices, such as the Tuskegee Syphilis Study (see the activity under ‘Research’ later in this chapter) and the Nazi ‘medical’ experiments, brought to the public’s awareness through the Nuremberg Trials¹ (Beauchamp & Steinbock 1999; Coleman et al. 2008), that denied patients their rights and humanity.

In the 1970s, Beauchamp and Childress (1979) outlined a systematic framework for approaching bioethics and resolving dilemmas (principlism). This consisted of four principles: autonomy, beneficence, non-maleficence, and justice. Autonomy is respecting individuals and their rights, beneficence is doing good and ensuring that the benefits of any action outweigh the burdens, non-maleficence is avoiding causing harm, and justice means that advantages and burdens should be fairly shared (Beauchamp & Childress 1979). These four rules can be useful for public health (Parker et al. 2007) However, with the emphasis on individual autonomy, the bioethical precepts fall short of a suitable response to the problems of establishing cooperative public health strategies (Kenny et al. 2006).

In Chapter 1 we discussed the influence of the biomedical perspective on health. Similarly, although frameworks for public health ethics have partially derived from the bioethical tradition, public health ethics is now a distinct, albeit overlapping, discipline, thus limiting the use of bioethical models to public health practice (Callahan & Jennings 2002; Thomas et al. 2002; Thompson et al. 2003).

While medical ethics and bioethics primarily focus on the rights of the individual, such an approach can be at odds with public health practice, where the emphasis is primarily on the good of whole populations (Baum et al. 2007; Callahan & Jennings 2002; Coleman et al. 2008; Mann 1997; Thomas et al. 2002). Thus, the overarching values of public health often require giving precedence to the needs and rights of the population (many individuals) over those of specific individuals (Bayer & Fairchild 2004). In addition, public health, unlike medicine, focuses more on preventing disease than treating it (Callahan & Jennings 2002; Thomas et al. 2002). Paradoxically, at the same time, public health ethics has to keep in mind that those populations are made up of specific individuals; thus individual rights remain relevant too.

Appropriate public health ethics call for a model that can bridge the gap between the individual and the communal good, illuminate the connection between individual and family health care and public health, and acknowledge the vital influence of socioeconomic factors on health (see Chapter 6). Moreover, any ethical approach must be sufficiently adaptable to keep up with the constant change in the variety of factors that influence public health (Fry et al. 2004).

Related law and human rights discourse

There is an intricate relationship between public health, law, political philosophy and human rights. Although distinct social institutions, ethics and law are all crucial tools for regulating behaviour, they work in partnership to provide guidance for public health. Practitioners must use their judgement and sense of responsibility to make decisions within the boundaries of the law. Ethics is a reflective procedure best performed with other people and entails investigating and evaluating any proposed strategy, together with giving good reasons for any action – particularly when the law has nothing specific to say about the issue until after action has already been taken. There are frequently no ‘correct’ solutions, especially when there are limited scientific data available. Thus, being able to team up with others to pinpoint and reflect on all the potential actions and ethical implications will enable rational decisions to be identified (Bernheim 2005).

Human rights

One of the challenges with a rights-based framework is that expressions such as ‘the right to equal opportunity’ (see below for more on equality and equity) and ‘the right to health’ are imprecise; they cannot be clarified without elucidating who has a duty to ensure access to each theoretical right (Leeder 2004; O’Neill 2002). Moreover, ‘rights’ has a different meaning in a legal context, in contrast to its meaning in a political or rhetorical context. In addition, rights often intersect or clash; for example, the right to privacy is in opposition to the right of the public to be protected from infectious disease. Some scholars have asserted that public health disregards individual rights to liberty, autonomy, privacy and property rights; however, Gostin (2001) rejects this – in the public health paradigm these are still respected, but they often must be overridden by the communal good. Or as others have put it, the rights of many individuals are seen to outweigh the conflicting rights of a few individuals.

When talking about the ‘right to equal opportunity’, we also need to distinguish between ‘equity’ and ‘equality’. Essentially, equity is about fairness (WHO 1996). The following quote illustrates the differences between these two concepts:

Equity in health is not the same as equality in health status. Inequalities in health status between individuals and populations are inevitable consequences of genetic differences, of different social and economic conditions, or a result of personal lifestyle choices. Inequities occur as a consequence of differences in opportunity which result, for example, in unequal access to health services, to nutritious food, adequate housing and so on. In such cases, inequalities in health status arise as a consequence of inequities in opportunities in life (WHO 1998 p 7).

Thus, equity is about having equal opportunities to health-enhancing factors, not equal (health) status.

Clearly, public health emphasises populations and is concerned with the determinants of health, many of which are beyond the individual’s control. Accordingly, a paradigm that articulates values in terms of people’s relationships with their social and structural environments may be more appropriate to public health’s aims than one that is more individually focussed (Mann 1997).

The basis for human rights, ‘within the United Nations system is the international Bill of Human Rights comprising the United Nations Charter, the Universal Declaration of Human Rights, and two International Covenants of Human Rights’ (Gostin 2003 p 183). The Universal Declaration of Human Rights was adopted in 1948 by the General Assembly of the United Nations. This edict provides a rights-based model for a public health code of ethics (See Chapter 3, p 55 for Article 25).

Mann (1997) claims that the human rights-based paradigm provides a more practical framework, language and guidance for contemporary public health ethics, rather than one modified from medical, biomedical or earlier public health ethics, because human rights discourse and law originated completely beyond the health sphere. Thus the language of human rights may be more appropriate for dealing with the determinants of health that are also external to the health sphere, such as housing, education and transport. Furthermore, human rights paradigms look to identify the societal necessities for human wellbeing and therefore address the social determinants of health (Mann 1997). Conversely, Porter (2006) critiques the human rights model for public health as a Western-dominated, consequentialist paradigm. That is, what makes this approach any more valid or desirable than any other ethical model? (Later in the chapter we examine a related concept – cultural relativism.)

Gostin (2001) indicates four areas where ethics can facilitate public health to fulfil its purpose: the first is by helping to define the meaning of ‘public health professionalism’ and ‘ethical practice’; the second is leading dialogue on the moral value of the community’s wellbeing; the third is addressing the familiar issues confronting public health practitioners; and lastly, facilitating advocacy to improve the population’s health.