In these ways, public health ethics builds on its overarching disciplines of public health and ethics. Nor does it cover public health's promotion of health and well-being across a number of initiatives. However, even this more holistic definition does not sufficiently clarify the meaning of "public" in public health.
Public health practice requires an increasing appreciation of the complementary roles that facts and values play in making and justifying decisions. Health messages can often inform the public about the scientific rationale underlying public health interventions. Thus, successfully implementing public health actions will often involve balancing the attitudes, interests and values of the public in relation to core public health values.
Two mundane features of public health practice often serve to obscure value assumptions: shared core values and standard practices. Stakeholders representing industry, workers or healthcare professionals may have different views on a safe level of exposure.
Ethics and Morality
Ethical Principles
Given the need for flexibility, some prefer not to speak of ethical principles, but of "general moral considerations" that can provide guidance in public health practice (Childress et al. 2002. In any case, a complex ethical challenge that stakeholders with Competing moral demands often require consideration of a variety of ethical principles and theories to address the situation and justify a proposed intervention.For these reasons, it would be useful to examine various ethical theories used in public health ethics and to to provide at the end of the chapter a framework generally applicable to ethical issues arising in public health.
Ethical Theories
Once established, virtues readily become the standards of obligation and accountability to evaluate professional performance and function similarly to the rules and principles of duty discussed below. Holding public health institutions accountable for the professional competence of their employees illustrates virtue ethics (Public Health leadership Society 2002. In assessing whether an action is right or wrong, deontology ignores the consideration of harmful or beneficial consequences and relies on this rules of duty to serve as standards of judgment.
People usually have rules of duty or obligations in mind when they talk about ethical standards or worry that standards no longer work. Duties: Ethical rules or orders that limit one's actions or define obligations owed to others. Thus, the right to freedom of expression presupposes a duty to respect the right of others to speak, while the obligation in the field of public health to ensure the conditions for maintaining health presupposes a right to health.
A person of moral goodwill does the right thing for its own sake, which means acting simply for the sake of duty. For Kant, basing the decision about one's action on duty alone without considering the possible good or bad consequences of the action is the only legitimate basis for moral action. Kant conceives of duty as the essential expression of autonomy, which may come as a surprise to those who equate autonomy with free rational choice or even simply following one's preferences without interference.
Such mutual respect in determining the moral laws that will bind one's actions differs significantly from insisting on non-interference with free individual choice, let alone personal preferences. Conversely, the aspiration behind Kant's view of autonomy aligns well with the public health obligation to address collective problems through collective action. For utilitarianism, the judgment of the rightness of an action depends on an assessment of the result or subsequent practical outcome rather than on its conformity with principles of duty.
Because the utilitarian approach seeks to define and promote the collective good based on aggregate measures, it is willing to justify public health interventions.
Law Versus Ethics
Utilitarianism considers ethically best that action that will result in the greatest net benefits over harms. Regardless of whether it takes the form of guidelines or law, research ethics will govern only a fraction of the ethical issues that the field of public health must address. In many areas of public health practice, there are no specific ethical guidelines or regulations.
To address ethical challenges in these areas or to address emerging challenges, the ethical practice of public health therefore requires the ability to use common ethical frameworks. Ethics, science, budgets or politics, each in its own way, can also limit the scope of action. Public health practitioners and officials must therefore first conduct a feasibility analysis to determine the relevant limits on possible interventions or policies.
Determining these limits will rarely limit the scope of action to a single possible course of action. As a result, the ethical challenges facing public health practitioners rarely involve stark choices between right or wrong, good or evil. The hard choices more often involve choosing the best alternative among competing goods, each of which to a greater or lesser extent realizes the public health goal and embodies relevant stakeholder values.
Alternatives must all achieve the public health objective and incorporate the perspectives and values of experts and relevant stakeholders. To decide on the best alternative, consideration must be given to how it will achieve the public health objective in a particular context and in relation to the stakeholders. The preceding account highlights why public health practitioners must see ethics as something more than a compliance issue.
It transcends compliance because public health ethics includes practical decision-making, which should include stakeholder analysis, the integration of stakeholder values into the design of alternatives, and a fair, transparent consultation process to evaluate alternatives.
Public Health Ethics
- Research Ethics , Clinical Ethics, and Bioethics : Principlism and the Four Principles
- Contrast between Clinical Ethics and Public Health Ethics
- Individual Versus Relational Autonomy
- Personal Autonomy as a Presumptive Value of Liberal Democracy
Since these four principles are applicable to health and research, they are also relevant to public health, but having emerged to solve problems in other fields, they must be adapted to a public health context. Even then, they still fall short in terms of solving the ethical challenges that arise in public health. It can be argued that this extension of bioethics beyond clinical ethics to population issues moves bioethics into the arena of public health ethics (Callahan and Jennings 2002.
While Kant's other-focused idea of moral autonomy harmonizes well with collective decision-making, the emphasis on non-interference in personal choice often creates barriers to the implementation of public health interventions. Because public health and clinical practice may overlap, the items in the respective columns represent trends along a continuum rather than stark opposites. Where separate agencies carry out public health services and medical care, these contrasts can be greater.
The overlap between public health and clinical practice makes it even more important to emphasize the differences between these two aspects so that distinctive features of public health ethics emerge. Authority based on law, an important tool of public health policy for creating health regulations. As a result, prevailing political philosophies and culture will necessarily shape the way public health functions.
It makes less sense in the much wider sphere of public health activities where social interactions and the interdependence of people come into play. Because public health considers the relationship between individuals and the collective good, it necessarily has a political dimension. How a country's political culture balances this relationship will drive and constrain public health practice and thus shape the nature of the ethical frameworks that are appropriate for a country's politics (Hyder et al. 2008.
In the short history of public health ethics, the most important ethical frameworks have emerged in the political context of liberal democracy. Many of these frameworks reflect the tensions between public health's obligation to act collectively for the common good and the presumed value of personal autonomy. 6, Jennings considers the relative merits of these approaches in his overview of the ethical issues in the environmental and occupational environment.
Ethical Frameworks
The following three-step framework is a straightforward tool to help practitioners analyze ethical tensions in a given context. It addresses Daniels' difficult question directly by considering the supposed prioritization of health care for the sickest relative to the public health value of saving the greatest life in a pandemic.
A Three-Step Approach to Public Health Decision Making
An Approach to Ethical Analysis and Justifi cation in Context
What are the short-term and long-term options based on the assessment of the public health issue and the context in Step I. Benefit: Whether the public health measure creates the best balance between benefits and harms and other costs. Respect for individual and community interests: Do public health interventions respect self-determination and human rights, as well as civic roles and community values (eg, trustworthiness, solidarity) (Dawson and Jennings 2012.
Other moral considerations in public health: Are there other moral considerations in public health that are important to consider. Necessity: Is the action necessary (ie, will disregarding a conflicting ethical norm achieve an important public health goal). Drawing on the questions in Stage I, health officials can first clarify the harms and risks and the goals of public health efforts.
The public health objectives are to prevent the transmission of tuberculosis and to ensure that the child receives appropriate care. Contact tracing and informing partners have historically been important tools for public health officials, although these interventions can raise thorny ethical tensions that require health officials to justify their decisions. Making difficult public health choices thus implies important social, cultural and political norms embedded in a particular context and stakeholder community (Childress and Bernheim 2008).
Context specifically includes attention to stakeholders and relationships between public health stakeholders and community members, including the shared understanding of their roles, responsibilities and collaborations. Engaging stakeholders and addressing claims, especially those of the people most affected by a public health problem, in ethical analysis is particularly important and can sometimes support and strengthen the collaboration and coherence needed for public acceptance of a decision. Public health professionals must often decide how best to realize several important societal norms and values when pursuing public health goals.
Ethical tensions occur in public health and sometimes require an important principle, value, or moral consideration to take a justified public health action.
