Chapter 1: Global Cases, Practice, and Context

The commitment to science as a value stance often becomes apparent only in relation to people who distrust science or prioritize other value commitments such as economic interests or religion. Public health values science by endeavoring to base interventions and policies on the best available data and evidence-based practices. That endeavor entails a commitment to conduct surveillance and research , because only by understanding the social burden of disease and its underlying or structural causes can public health impact the health of the entire population . The qualifier “best available” is a reminder of the need to continuously improve practice and not rely on tradition or current practices. It also reminds us that during emergencies, time and resource constraints limit the ability to gather evidence.

Public health values community in two obvious senses. First, it recognizes that the success of most health interventions depends on a community’s acceptance, cooperation, or participation . Second, it recognizes that to be successful, public health must respect the community’s values and gain the trust of its members. Yet there is a third, deeper sense in which community represents a value. A community is, to emphasize again, neither a statistical abstraction nor a mere aggregate of individuals but rather a network of relationships and emotional bonds between people sharing a life in common organized through a political and moral order (Jennings 2007). The value that best reflects this fundamental, relational character of social life is solidarity. Solidarity can remain unspoken yet operative because it forms the basis of social life and collective action. Just as communities are not mere aggregates of individuals, neither are the agencies or organizations that make the collective decisions that affect the community. Personal interests, to be sure, can motivate individuals, but the felt recognition of a common plight, that we are all in it together, underlies the collective decisions society and public health must make to solve collective problems. To say that public health values community means that it values solidarity, even when solidarity remains unacknowledged as is often the case (Dawson and Jennings 2012).

Despite greater individual access to health care and advances in public health, high burdens of disease remain across much of the globe. Some differences in disease burden result from genetics and some from variable risks of exposure to infectious agents and other threats, but most of the differential burden arises from social, economic, and political conditions . These conditions include poverty, lack of education, and discrimination against particular social groups and often reflect historical injustices or long-standing systemic, structural deficiencies. Collectively, these conditions have come to be known as social determinants of health (Blane 1999). Greater access to individual health care can mitigate their effect, but an adequate response to them requires concerted public action to address their underlying causes.

Whether comparing countries or groups within countries, social stratification by social determinants correlates with differences in health status (Marmot 2007). These health differences have aroused widespread concern, but how one defines them significantly affects public health practice (Braveman 2006). In particular, distinguishing health disparity from health inequity is critical. As a comparative indicator of health status, health disparity is a neutral, epidemiologic term that need not imply an ethical obligation to remedy. Health disparities , however, can and frequently do reflect underlying inequities. WHO defines health inequities as health differences that are “socially produced; systematic in their distribution across the population ; and unfair” (WHO 2007). Terms like “inequity” and “unfair” are ethical terms that imply an obligation to redress an injustice. Justice has a range of meanings that include giving people what they deserve or are owed and distributing goods and services fairly. Justice in a medical context often involves the individual’s access to health services. In public health, discussions of health equity usually involve questions of how to distribute health benefits fairly or how to achieve better health outcomes among communities or groups that suffer health inequities . Attaining greater equity might involve the politically controversial strategy of disproportionally distributing resources within a population , by, for example, distributing more to those most in need. A less-controversial strategy is to improve health outcomes for all, even while devoting special efforts to those most in need. WHO defines health equity as “the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically, or geographically” (WHO 2007).

Achieving health equity is most urgent for groups who have experienced histories of marginalization and discrimination and who continue to experience higher rates of illness and premature deaths than members of the mainstream population . Especially for these groups, “social injustice is killing people on a grand scale” (WHO 2008). Realizing the goal of social justice with respect to health means achieving health equity. Doing so requires not only a fair distribution of health outcomes , it also means that “ideally everyone should have a fair opportunity to attain their full health potential” and that “no one should be disadvantaged from achieving this potential, if it can be avoided” (Whitehead 1992). For many, these goals imply that social justice obligates public health to improve any social condition that prevents people from maintaining a standard of life adequate to maintain health (Powers and Faden 2006). Although some believe that improving social conditions that affect health overextends public health’s mandate, such a broad mandate is arguably consistent with both Winslow’s and IOM’s definitions of public health. Moreover, such a broad mandate has both nineteenth century precursors in the social medicine movement and more recent precedents in the “Health for All” strategy that emphasizes health promotion and the “Health in All Policies” strategy (Kickbusch 2003; Freiler et al. 2013). But a major milestone was reached with the 2008 report of the WHO Commission on Social Determinants of Health that sought to “marshal the evidence on what can be done to promote health equity , and to foster a global movement to achieve it” (WHO 2008). and essential services, establish policies that provide an equitable basis for health improvement, and gather and monitor data on health equity , achieving equity ultimately will depend on the cooperation of government and civil society (Blas et al. 2008).

Two mundane features of public health practice often serve to conceal value assumptions: shared core values and standard practice. First, sharing values can render them invisible as assumptions, until they unexpectedly become contested. Unwelcome surprises occur when interventions that presuppose core values affect stakeholders who do not share those values, as when parents refuse to have children vaccinated based on media hearsay or individuals reject a highly effective program as governmental intrusion. Avoiding such surprises begins with becoming aware of one’s own value presuppositions in relation to those of other stakeholders and community members. Second, routine use of evidence-based standards can conceal underlying value assumptions. If developed and tested to address a known health problem, as is common, an intervention’s purpose and effectiveness is taken for granted. Standard interventions, then, generally require no more justification than noting their standard status or seeing that “the facts dictated” their use. “Dictating” facts are indicators that trigger use of a standard intervention (e.g., meeting the criteria of a case definition or documenting exposure to a dangerous level of a contaminant). Such “dictating facts,” more properly speaking, only indicate the appropriate intervention but cannot literally dictate that anything be done. What in the end dictate actions are the values, goals, and obligations that the standard intervention presupposes and that practitioners tacitly ratify each time they apply the standard. In other words, values, goals, and obligations , even when tacit, form a necessary bridge between knowledge and action.

Though standard practices tacitly incorporate ethical principles , they seldom raise ethical challenges. Challenges more typically arise in unusual or extreme situations where standards are not yet in place, are changing, or are competing. These situations include emergency operations, foreign cultural settings, emergent fields with innovative interventions, or periods of severe budget constraints that force prioritization of programs. In such challenging situations where no value consensus exists or where evidence does not point to a single course of action, public health ethics provides a process to determine and justify a course of action. That justification can incorporate a number of factors: evidence base for the intervention, cost effectiveness , analysis of relevant ethical rules and stakeholder values , a creative design of options or alternatives that embody these values, and a fair and transparent decision-making process that incorporates stakeholder contributions.

Recognizing one’s own value assumptions in relation to those of the public will be critical for implementing new interventions wherever success depends on public acceptance. The public will not embrace interventions that embody or presuppose values that clash with community values or whose relative importance is low compared to other community values. Members of the public generally are more committed to their political views, ethical and religious values, and an intervention’s impact on them personally than to scientific evidence or community impact. Public health practitioners need to recognize that no matter how compelling to them, community impact and scientific rationale seldom resonate as deeply with the public. Consequently, in communicating, public health practitioners need to supplement scientific messaging with dialogue, an appeal to common values, or enlistment of spokespersons who share the value orientation of the relevant stakeholder s or community. Regarding some controversial matters, ultimate success in implementing an intervention may require building a social consensus (Ortmann and Iskander 2013).

In certain situations, untangling factual claims based on science from value judgments is critical for success. For example, suppose independent investigators have scientifically verified the level of worker exposure to a toxic chemical used in industry. Determining what level of exposure would be safe, however, remains a value judgment that depends on the degree of concern that people have about safety . Placing a higher value on safety might result in stricter controls that decrease risk for workers, but the financial costs of decreasing risks could cut industry profits or jobs, even as health costs fall. Stakeholders representing industry, workers, or public health practitioners might have different positions regarding a safe level of exposure. To make a good decision about a safe exposure level, the value of safety might have to be discussed and weighed in relation to business, employment, and health considerations. However, these varying positions regarding safety need not imply disregard for safety or disagreement on the underlying facts. Rather, they illustrate that conflicting value judgments can coexist despite a consensus on both the underlying facts and the importance of a particular value such as safety .

Directly addressing the value conflicts in such situations through ethical deliberation makes more sense than calling into question the underlying facts and can lead to better, fairer, and more transparent decisions. It is also important to recognize that doubting the science often represents an underlying value dispute masquerading as a scientific dispute (Brunk et al. 1991). Sowing doubt on scientific assessments merely as a tactic to oppose an evidence-based policy or recommendation undermines science. This doubt can exert pressure to test and retest results, raising the bar for scientific validity ever higher (Michaels 2008). The solution is not to litigate, as it were, the science, but to recognize that communicating risk is a social process that goes beyond science messaging and must take cultural attitudes, perceptions, and symbolic meanings into account (Krimsky and Plough 1988). Where profound value disagreements prevail, public health legitimately prioritizes its core values but cannot speak for everyone. Stakeholder views require a fair hearing, whether through media research , stakeholder analysis, or direct solicitation of input from individuals, focus groups, or public meetings. By design, a fair, transparent ethical decision-making procedure can help determine what value tradeoffs are feasible and what values may be nonnegotiable. Such a deliberative procedure can help to gain public acceptance and become part of the justification for a course of action.

To those accustomed to rigorous research methods and evidence-based standards of practice, navigating the world of ethical values and rules can be perplexing. Values, as the term itself implies, manifest valences, that is, variable degrees of commitment or estimations of importance along a continuum. Individuals rank values differently, change their rankings, and will alter their relative ranking of values in different contexts. The range of options for ethical rules are far more limited, namely, to obey or not obey. Nevertheless, the ethical rules governing particular situations also vary from country to country or even from jurisdiction to jurisdiction within a country. Despite this variability in values and ethical rules, reducing ethical judgment to mere opinion or to a consensus of opinion relative only to personal or cultural preferences would be a mistake. Ethical values and rules enjoy the approval of history, custom, law , and religious tradition, but they also find anchor biologically, psychologically, and socially in human life. Value judgments and ethical determinations, then, are not relative as much as correlative; that is, they correlate and resonate with these deeper roots of human life that we share. If humans indeed share a set of fundamental values, then ethical conflicts primarily reflect differences in prioritizing values in a particular context, rather than a fundamental disagreement about values. This point of view provides grounds for optimism about the possibility of finding a deeper basis for understanding and mutual respect , if not agreement, when ethical tensions surface.

The diversity of ethical theories does not imply their mutual opposition so much as points to the extensive range of the moral landscape and the need to illuminate its various contours. A helpful way of illuminating this landscape is to distinguish theories depending on whether they focus on the actor, the action, or the results of action. To illustrate this particular way of carving up the moral landscape, Table 1.1 describes some well-known ethical theories.

Aristotle’s virtue ethics is an ethical theory that focuses on the moral character of the actor or agent (Bartlett and Collins 2011). Classic virtues are dispositions or stable patterns of behavior that lie between extremes of vice; courage, for example, lies between the extremes of cowardice and foolhardiness in taking risks. Habit and practice are necessary to develop virtues whose possession we equate with good character and that equip a person to be effective in society or an organization. Because good character translates into virtuous action that others aspire to emulate, we tacitly invoke virtue ethics whenever we ask how an outstanding public figure or health leader would handle a situation. In a modern professional context, virtues also include the skills the profession has identified that lead to success in that profession and which professional education and training instill in practitioners. 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). More recently, th e capabilities approach has exploited the potential of virtue ethics to guide decisions about policy or interventions in a way that goes beyond matters of professional training and responsibilities. This approach takes a broader developmental view of human agency and capacity building. It conceives health as a fundamental capability necessary for individuals to succeed in society, one on which many further capabilities depend (Sen 2009; Ruger 2010).

An ethical theory that focuses on action or, more properly, the rules governing action, is deontology. The word deontology comes from the ancient Greek word, deontos, which means duty. Because duties oblige us to obey rules that govern actions or conduct, they bind or constrain the will ahead of action. In judging whether an action is right or wrong, deontology ignores consideration of harmful or beneficial consequences and relies on these rules of duty to serve as the standard of judgment. People usually have rules of duty or obligation in mind when they speak of ethical standards or worry that standards are breaking down. Examples of these rules include religious commandments to honor parents , not lie, or not steal and rules of social interaction such as treating people fairly, doing them no harm, or respecting their rights. Rights often are said to stand in reciprocal relation to duties. Thus, the right to free speech presupposes a duty to respect the right of others to speak or the public health obligation to ensure conditions for maintaining health presupposes a right to health .

Deontology as a theory owes most to Im manuel Kant’s view of the “good will” and his closely linked account of autonomy . A person of morally good will does the right thing for its own sake, which means acting purely for the sake of duty. Duties are moral rules or laws that bind the will and limit the scope of action. For Kant, basing decision for one’s action solely on duty without regard to the potential good or bad consequences of the action is the only legitimate basis for moral action. Kant even goes so far as to say that “a free will and a will under moral laws are one and the same” (Gregor et al. 2012).

Kant conceives duty as the quintessential expression of autonomy , which may come as a surprise to those who equate autonomy with rational free choice or even just following one’s preferences without interference. However, the meaning of autonomy for Kant derives from its literal meaning in Greek, autos (self) and nomos (law) ; namely, self-legislating. Autonomy enacts from within the moral rules and principles that bind the will and guide action. However, not every self-originating impulse should be obeyed; only actions conceivable as universal laws morally bind the will. Morally laying down the law for oneself entails legislating for everyone, but universally legislating does not mean asserting one’s will over others. Nor does it mean that the ethical content of a moral law or duty is valid eternally and everywhere. Rather, it refers to the “categorical imperative” an unconditional requirement for an action to be moral. To qualify as a duty, a rule that commands action must apply to every rational person. Stealing, for example, could never qualify as a duty , because a situation where everyone steals from everyone else would undercut the one-sided advantage of stealing that the thief hopes to exploit. Although self-directed, autonomous action is necessarily other-regarding.

Kant maintains that the categorical imperative can be expressed in two other ways equivalent to universality, namely, “respect for humanity” and a “kingdom of ends” (Gregor et al. 2012). In each, this other-regarding dimension of autonomy is evident. Respecting humanity means never treating persons as mere means or objects but always treating them as ends, that is, regarding them as fellow autonomous agents. Autonomously agreeing on actions, interventions, or policies requires that decision makers mutually consider and understand their reasons for action and be willing to abide by the rules derived from these reasons as laws they collectively impose upon themselves (O’Neill 2002).

The idea of a fellowship of mutual consideration comes out most clearly in Kant’s concept of a kingdom of ends. This concept is really the ideal of a systematic union or commonwealth of autonomous individuals making law s that apply to everyone. This ideal presupposes that ethical deliberation places respect for others as ends, as autonomous agents, above self-interest. The core idea is that we only consider actions that could gain acceptance by a community in which all see themselves as sovereigns who lay down universal laws binding on themselves and others. The hope is that the body of law governing society progressively embodies this ideal. Such mutual regard in laying down the moral laws that will bind one’s actions differs significantly from insistence on noninterference with individual free choice, let alone with personal preferences. Conversely, the aspiration behind Kant’s view of autonomy harmonizes well with the public health obligation to address collective problems through collective action.

For utilitarianism , judging the rightness of an action depends on an estimation of its subsequent practical outcome or result rather than on its conformity to principles of duty . Utilitarianism considers ethically best that course of action that will result in the greatest net benefits over harms. A utilitarian approach underlies cost-benefit analyses that weigh an intervention’s costs (risks , harms, burdens, or disadvantages) against its benefits (advantages, utility, improvements, cost savings). In addition to its focus on consequences, utilitarianism is egalitarian, communitarian, and scientific in outlook. It is egalitarian in considering everyone’s benefit and equally weighting each person’s good, as opposed to privileging certain people. It is communitarian in attempting to increase benefits to society rather than individuals, seeking the “greatest good for the greatest number.” It endeavors to be scientific by quantifying harms and benefits, accounting for probability, and calculating net benefit. Calculating net benefits over harms is less problematic when relevant factors employ a common scale of measurement, for example, weighing the financial costs of treating a disease with the cost savings from preventing that disease. Comparing different outcomes (e.g., financial costs versus quality-adjusted life years ) sometimes involves difficult judgments about the relative value of each outcome. Because the utilitarian approach seeks to determine and promote the collective good based on aggregate measures, it readily lends itself to justifying public health interventions .

In theory, deontologically evaluating a past or proposed action is a straightforward binary determination of compliance or noncompliance with a legal or ethical rule. In practice, however, defining a rule’s scope or determining exactly which actions fall under it can prove difficult. Moreover, when different rules apply, determining which should take precedence often becomes problematic, especially when they conflict . Lying to protect a relative, for example, can put the duty to speak truthfully into conflict with familial obligations . Determining which rule takes precedence can involve reasoning clearly from ethical principles , weighing the underlying values embodied in the law , or considering the practical impact of the intervention in context. Because laws demand compliance , they are more rigid. Additional legal stipulations can prioritize or specify how to apply laws in certain situations, but doing so increases their complexity. Ethical guidelines operate more flexibly than rigid, compulsory laws and more readily accommodate compromise. With ethical guidelines, decision makers can consider and rank the underlying values the ethical rules serve to promote. Doing so allows for trade-offs between competing ethical considerations and for deciding which values it makes sense to prioritize in the given context. Conversely, law’s comparative rigidity can be a virtue where only stricter oversight and enforcement will ensure compliance and establish order.

Across cultures, legal, ethical, and religious rules prohibiting basic offenses such as lying, theft and murder show considerable overlap. However, cultures vary in exactly which rules are matters of individual choice and which are matters of legal enforcement and punishment. This variability also applies to the status of rules and standards governing research on human subjects. Even within a country, significant variability can prevail in whether human subjects’ research rules and standards are legal regulations or ethical guidelines (U.S. Department of Health and Human Services 2015). Some se e the lack of legal regulation as a breach in protections, but others prefer guidelines, arguing that regulations tie reviewer hands, making it more difficult to make trade-offs or nuanced judgments based on moral discernment of the particulars of each case (Verweij and Dawson 2009). Because each approach offers advantages and disadvantages, political culture and local context must ultimately decide whether human subjects’ research rules exist as enforceable regulations or ethical guidelines .

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 emergent challenges, the ethical practice of public health therefore requires the ability to use general ethical frameworks. Such frameworks can employ checklists of questions and stepwise procedures. However, because novel challenges continually emerge and changing contexts introduce nuances no set of rules can anticipate, public health professionals ultimately need to practice ethical decision making over time in order to cultivate moral judgment and discernment.

By laying down and enforcing what may, must, or cannot be done, legal rules function as boundaries of acceptable behavior. Ethics, science, budgets or politics, each in its own way, also can restrict the scope of action. Public health practitioners and officials therefore first need to conduct a feasibility analysis to determine the relevant limits on possible interventions or policies. Determining these limits seldom will restrict the scope of action to a single possible course. Given multiple possibilities, most people will aspire to the best course of action beyond the legal floor of minimally acceptable behavior yet within the other relevant limits. As a result, the ethical challenges public health practitioners face seldom involve stark choices between right or wrong, good or evil. A good feasibility analysis will have ruled out any unethical or illegal options or alternative courses of action in advance. Rather, the tough choices more frequently involve selecting the best alternative from among competing goods, each of which to a greater or lesser degree realizes the public health goal and embodies relevant stakeholder values.

Whereas determining and complying with the various limits on action is largely an analytic process, designing alternatives is a synthetic, creative process. Alternatives should all realize the public health goal and incorporate the perspectives and values of subject matter experts and relevant stakeholders. Deciding upon the best alternative must take into account how it will realize the public health goal in a particular context and with respect to the stakeholders. For example, advocating contraceptives to reduce unwanted teen pregnancy might seem to promise success based on efficacy studies, but ethical controversy could render such a program less than optimal in some contexts. Political culture or social norms can confer partisan advantage or disadvantage to some alternatives, while other alternatives may enjoy an advantage because of the experience and expertise of a health department. Whatever alternative practitioners finally choose, their choice will presuppose a prioritizing of values. The foregoing account highlights why public health practitioners need to see ethics as something more than a compliance matter. It transcends compliance because public health ethics also involves practical decision making, which should include stakeholder analysis, the incorporation of stakeholder values in the design of alternatives, and a fair, transparent deliberative process to evaluate alternatives.

Our discussion of these documents has only highlighted key provisions of what is required to ensure the safety of human subjects. CIOMS’s most recent research guidelines (2002), for example, contain more than 60 pages of text, explanation, and commentary. But ensuring ethical conduct and scientific integrity in research requires more than the oversight function of ethical review committees. It also requires extensive training not only in research ethics but also in a number of related areas. Training and guidelines should cover, among other things, mentoring of junior researchers, authorship and publications policy , conflicts of interest that arise in partnerships and collaborative science, and data acquisition, management, sharing and ownership. Ethics training can help develop moral judgment. The hope is that training and application will enable practitioners to reason about new, difficult, or ambiguous cases in morally discerning ways.

Clinical ethics address the ethical issues that arise in clinical practice. Until the advent of bioethics , medical professionalism emphasized the health care provider’s obligation to prioritize the patient’s welfare, the health care provider’s professional judgment about what would most benefit the patient, and the importance of establishing patient trust . The traditional model of clinical ethics was frankly paternalistic . Under the influence of bioethics, many health care providers began embracing a more patient-centered model of care that emphasized patient autonomy and informed consent . This patient-centered model conceives care as a contract between patient and provider. The emphasis on contracts strikes some as an inappropriate consumerist model that undervalues professional judgment and undermines patient trust in the medical profession. Tensions between these two models have led to a compromise that reasserts the importance of medical professionalism and clinical judgment, while acknowledging the importance of respecting patient autonomy (ABIM Foundation et al. 2002).

Bioethics has a range of meanings, the first of which applies to ethical issues brought about by advances in biomedicine and biotechnology . Ethical issues that arise from using life-sustaining technologies in end-of-life and beginning-of-life care epitomize this sense of bioethics. But bioethics also arose in response to medical paternalism and to the abuse of human subjects in medical research . Bioethics has championed informed consent , patient autonomy in doctor-patient relationships and the safety of human subjects in research. However, many bioethicists think the focus on clinical ethics and on personal autonomy unduly restricts bioethics’ purview. They advocate a more holistic, social justice approach in bioethics, which has been referred to as “population-based bioethics” or “integrative bioethics” (Sodeke 2012). It can be argued that this expansion of bioethics beyond clinical ethics into population issues moves bioethics into the arena of public health ethics (Callahan and Jennings 2002).

Principlism came into being in a 1979 document called the Belmont Report (U.S. Department of Health, Education, and Welfare 1979). The report was the work of the U.S. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research , which convened in 1974 partly in response to the exposé of the U.S. Public Health Service Tuskegee Syphilis Study. The Belmont Report became the basis for revising 45 CFR 46, the so-called Common Rule , part of the legally binding U.S. Code of Federal Regulations, governing the protection of human subjects (U.S. Department of Health and Human Services 2009). The Belmont Report clearly explained the underlying ethical principles that informed existing regulations and provided an ethical framework for thinking about subsequent regulations. Principlism has remained the predominant ethical framework in biomedical ethics (Beauchamp and Childress 2012). Its explanatory groundwork accounts for much of its success, but its relevance to medicine and research , the prestige that attaches to these fields, and its compatibility with liberal individualism also have played a role.

Beneficence (doing good) and nonmaleficence (doing no harm) date back to the Hippocratic Oath as medical principles. Collapsing them both into beneficence, as the Belmont Report does, underscores the practical consideration that biomedical decisions generally aim to optimize net benefit over harm, rather than to maximize only benefits or minimize only harms or risks . However, these principles are distinct, not mere opposites. Not doing harm has a certain priority (first, do no harm), because not benefitting someone seems a less serious offense than doing that person harm. That priority partly reflects the human tendency more readily to forgive overlooked benefits (errors of omission) than deliberate actions resulting in harm (errors of commission).

Justice has several meanings that include due process and fair deliberative procedure, properly assessing what people are owed or due, and equitable distribution of burdens and benefits. According to philosophic tradition, justice has always functioned dually, applying to individuals but more importantly serving as an overarching principle for adjudicating competing claims in relation to the group or to other members of society. The phrase, “social justice ,” then, is redundant but in political contexts marked by individualism serves as a reminder of justice’s social dimension. In fact, this phrase came into vogue in public health circles to counter the ideology of “market justice,” which views the equal access of individuals to the free market as a valid, reliable, and preferred means for sorting out issues of economic and social justice (Beauchamp 1976). The notion of health equity , which compares different groups, primarily refers to this social dimension of justice , although denial of access to health care, a contributing factor to health inequity , violates what the individual is owed.

Respect for persons emphasizes that individuals, as agents in charge of their own lives and bodies, have the right to make decisions and choices free from undue interference. Respect for persons forms the basis of informed consent , namely, the right of patients and human research subjects to be informed of, and to assent to, medical or research procedures they might undergo, especially procedures that pose potential harm or risk . Conducting research on human subjects or performing medical procedures on patients without their prior knowledge or consent in most cases violates their personal autonomy . However, health professionals have a special (i.e., paternal) obligation to look out for the welfare of people with diminished decisional capacity—such as those in a coma or the very young—and to protect them from harm.

These four principles were originally conceived as prima facie principles, that is, each expressed a self-evident though not absolutely binding obligation and none had an inherent priority over another. However, in many Western countries and in the United States in particular, respect for persons has dominated discussion in bioethics , clinical ethics, and research ethics where it often takes precedence as a moral consideration over the other principles. This ascendancy most likely reflects the high value that these countries place on liberty and freedom . At any rate, in public discourse generally and in public debate about public health interventions , respect for persons often amounts to an insistence on noninterference with individual free choice or with personal preferences. Although Kant’s other-regarding idea of moral autonomy , harmonizes well with collective decision making, the insistence on noninterference with personal choice often creates impediments to the implementation of public health interventions . In part for this reason, the social justice movement has had to challenge the emphasis on respect for persons in order to promote the public good and health equity .

The table makes clear that the Belmont principles of beneficence (seeking benefits), nonmaleficence (avoiding harm), respect for persons , and justice remain important in public health, but must be extended to accommodate the broader scope of public health interventions . This broader scope entails many types of professionals , interventions and policies that display a political and social dimension, and a wider range of activities such as community engagement, intersectoral collaboration , collective decision making, and governmental administration. As a result, prevailing political philosophies and culture will necessarily shape the way public health functions. The crucial point is that differences of scale that produce a higher order of complexity also produce qualitative differences that introduce different patterns of causation. Among other things, this means that social factors do not merely represent aggregated individual factors and so cannot always be addressed in the same way as individual factors.

These points about the foundational character of social relatedness, solidarity , interdependence , and communal decision making do not readily align with certain features of social contract theory , on whose principles liberal democracy is based. Whereas virtually every other political tradition conceives the sociopolitical realm as a natural feature of human life, social contract theory posits humankind’s original state, the state of nature, as one of solitary individualism . In this view, society or at least civil society come into existence voluntarily through a contract that creates government through the consent of the governed (Riley 1982). Although never seriously advanced as a scientific account of society’s origins, social contract theory nevertheless has exerted a powerful influence as a political founding myth. As such, it has made personal liberty , free choice, and consent of the governed presumptive values of societies whose governing political philosophy rests on social contract theory. By “presumptive,” we mean that the value, norm , or claim is assumed to be valid or have priority, so that the onus is on the person who objects to the presumption to justify a different value, norm, or claim.

Arguably, the primary aim of the harm principle is to promote the kind of individual self-development that benefits society rather than to champion every exercise of free choice. At any rate, some have sought to distinguish this edifying version of personal autonomy from an all-encompassing version that demands undue deference to any and all personal choices and preferences merely because they are personal (O’Neill 2002; Dawson 2011; Powers et al. 2012). Presuming, or insisting on, the validity of personal autonomy makes more sense in the delimited context of medicine and biomedical research on human subjects where an individual’s body is the focus of activity. It makes less sense in the far wider sphere of public health activity where social interactions and the interdependence of people come into play. Absolutizing personal autonomy in the sphere of public health would give effective veto power over every collective decision aimed at the public good to any individual who felt constrained by that decision. A more moderate version might distinguish levels of importance of personal choices and exercises of liberty . A collective decision concerning the public good could override some personal choices and limit liberty, even when they did not involve direct harm to others. Such decisions, when made in the context of a fair, transparent process of ethical deliberation involving stakeholders , are more likely to get buy-in from a community and less likely to be labeled paternalistic .

Because public health considers the relation between individuals and the collective good, it necessarily has a political dimension. How a country’s political culture balances this relation will drive and constrain public health practice and so shape the nature of the ethical frameworks that are appropriate to a country’s politics (Hyder et al. 2008). In the brief history of public health ethics, the most important ethics 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 presumptive value of personal autonomy . The principle of least infringement and Kass’s code of restraint illustrate the effort to mediate such tensions (Kass 2001). The code of restraint strives to balance autonomy claims against the obligation to safeguard community health by determining what intervention most effectively protects health while minimally infringing on liberty . In a liberal political context that recognizes Mill’s harm principle , this strategy justifies the trumping of personal autonomy as long as imminent harm threatens the populace, for example, in a deadly outbreak of contagious disease. But where the threat of harm to others is indirect or not immediate, as with the obesity epidemic, the harm principle less readily justifies a liberty-limiting intervention such as banning or taxing certain foods. Utilitarian approaches that weigh the health advantages of intervention and the disadvantages of obesity clearly support obesity intervention, but limiting interventions to those that do not restrict personal choices also have limited effectiveness . In Chap. 6, Jennings considers the relative merits of these approaches in his overview of the ethical issues in environmental and occupational public health. His discussion raises the question of the extent to which an ethical framework should adapt itself to the presumptive values of the political context or should reflect the nature of the practical field under investigation. To some extent, it must do both.

The three-step framework offered in the next section is designed to guide decision makers, through questions, to assess the ethical dimensions of a case, including which moral considerations (e.g., population utility or liberty ) may have more weight than others, given the issue or context. This contextual approach provides the flexibility and starting point for deliberation to accommodate the issues globally and to uncover the varying perspectives of stakeholders with potentially different presumptive moral norms (e.g., solidarity versus individual rights ).

Consider the following scenario described by Melnick (2015a). A family adopted several children from a developing country with a high tuberculosis (TB) prevalence, including multidrug-resistant TB (MDR-TB) . Screening on arrival revealed that the children were infected with TB but did not have active disease and were not contagious. The family has strong religious beliefs about medical care and refused treatment , immunizations, and other preventive care. The children were home-schooled, but they did attend community activities. Soon after arrival one of the teenage children developed TB symptoms, and after several months the family consulted a pediatrician who diagnosed active pulmonary TB. Cultures revealed that the child had MDR-TB. Directly observed treatment (DOT) is part of the standard of care for active TB in the United States , and the local health department nurse visited the family to provide DOT. The parents objected to the home visit, stating that DOT was an invasion of their privacy and parental rights. The health department has the statutory authority to require in-person DOT and even impose isolation of the case and removal from the family to protect the public’s health. What should health officials do? Drawing on questions in Step I, health officials might first clarify the harms and risks and the goals of public health action. The public health goals are to prevent TB transmission and ensure the child receives appropriate care. Requiring DOT creates risks for the child such as side effects from treatment and social and behavioral harms associated with isolation and loss of privacy during visits, and potential community harm, by driving cases underground. Who are the stakeholders , and what are their moral claims?

There are several stakeholders: the child, the child’s family (including parents but also several siblings), and the public, which expects the health department to protect the community from TB. Regarding moral claims, the child has some expectations of freedom of movement, and privacy ; the family has similar expectations regarding privacy, respect for parental rights, and the freedom to administer medications to their child at a convenient time and place. However, these claims are not absolute, and competing moral claims can outweigh them. The child has a moral claim that could compete with her parent’s claim, specifically, that receiving DOT will reduce the risk of inappropriate treatment and relapse compared to having her parents administer the medications. In addition, the public has a moral claim based on two expectations: (1) that the health department will protect the community from TB, and (2) that people contagious for TB and other infectious diseases will protect others by behaving in an appropriate manner, including staying home when contagious and cooperating with treatment recommendations. This is especially concerning in this case because the immigration health officials had discussed the risks with the parents, warning them to seek treatment as soon as the child developed symptoms, yet the parents waited several months before taking the child to a pediatrician (Melnick 2015a, 175).

Consider another short scenario that illustrates the value of exploring options under Step II. A new policy is being considered that would require parental consent for newborn screening . Parental consent currently is not required, although newborn testing is not conducted if there are parental objections. The health department has been asked to take a position on the pending policy. What position should the health department take? What are the options?

Options include mandatory screening without consent , routine screening with advance notification (Opt In), routine screening without advance notification (Opt Out) (i.e., screening and testing done unless the parents object), voluntary screening (i.e., screening requires full consent and might also include a pre- and post-counseling session with each new mother). Some arguments that might be offered against requiring parental consent focus on the fact that (1) the benefits of screening are obvious and substantial, relative to potential harms; (2) parents have few good reasons to justify parental refusal and place their child at risk for harm; (3) obtaining consent from each parent is difficult, costly, and an unwarranted expenditure of time and money; and (4) the history of newborn screening has become acceptable and routine. Some arguments that may be raised for requiring parental consent include (1) parental consent is necessary because refusal of newborn screening is reasonable given the increasing list of diseases included in the battery of newborn tests and the low probability of many of these diseases; (2) newborn screening can have adverse consequences such as psychological harms associated with false positive tests; (3) long-term parental caretaking is enhanced when parents are included in all clinical decisions about their children ; and (4) the process of obtaining consent need not be time-consuming or burdensome but rather can help enhance the health professional-patient relationship (CDC 2012). Which arguments are stronger, and which of the options are the most ethically justifiable? The answer may depend on the social and political context in which the issue is considered, and which ethical values carry weight in that context. Whether there were presumptive values in place would be explored through the questions in Step I, which examines previous cases, the applicable laws and policies, and stakeholder claims in context. So, for example, in a society that has a strong moral norm or presumption for solidarity , there could be a presumption for continuing population newborn screening without parental consent . On the other hand, for a society that has a liberal political context that has a presumption for individual liberty , there may be a presumption for an option that seeks more explicit consent from parents . In either context, the presumptive moral norms are not determinative but are rebuttable, so the arguments or reasons to override those norms must be stronger.

Consider a third case from public health practice in which a person (the index case) infected with primary syphilis and HIV refuses to provide contact information for his wife, insisting that he and his wife had not had sexual relations for several years. Contact tracing and partner notification have been important tools historically for public health officials, although these interventions can involve thorny ethical tensions, requiring health officials to justify their decisions. In this type of situation, health officers will consider several options, starting with those that infringe least on the index case’s choices. For example, they might first provide to the index case additional information and assurance about confidentiality while allowing him to notify his wife voluntarily, either alone or with the help of public health workers. If this proves unsuccessful, other interventions might be considered, such as incentives, the threat of restrictions such as isolation, or attempts to notify the wife without his knowledge or consent . Each of these options would be determined in context, using the questions in Step III. Questions considered may include (1) Would the options likely accomplish the goal of warning and testing the wife without risking greater harm or possible adverse outcomes for the wife (e.g., domestic violence, loss of income, or loss of housing)? (2) Is there significant concern about a risk of harm to others, such as family members or children , so that the burdens and benefits of the action would not be distributed fairly? (3) Is the action the least restrictive of the important moral claims of the stakeholders ? (4) Is it necessary now to override conflicting claims to achieve the public health goal? Answering the questions in Step III helps decision makers consider whether actions are justifiable. As one health officer explains, “Public health officials should justify their decisions with deliberations that build not only community support and trust , but also build support and trust from the individuals and families directly affected” (Melnick 2015b).

As the scenarios illustrate, public health is a social and political undertaking. Thus, making difficult choices in public health implicates important social, cultural, and political norms embedded in a particular context and community of stakeholders (Childress and Bernheim 2008). Regardless of whether decision makers work in a government public health agency, community nonprofit, nongovernmental organization (NGO) from another country, or a global organization, decision makers must rigorously assess the public health issue in context, to minimally be able to act “in ways that preserve the moral foundations of social collaboration” at the core of collective health activity (Calabresi and Bobbitt 1978).

The context specifically includes attention to stakeholders and relationships among public health stakeholders and community members, including the common understanding of their roles, obligations , and collaborations . Especially in global public health , it is important to note that even the decision makers are stakeholders, in some sense, and often, when they are health professionals , they have their own social-cultural norms and their own professional codes that can provide guidance. Appeals to the codes of particular professions, however, do not provide a sufficient justification for a public health decision, since justifications should be grounded in a society’s widely shared ethical values and norms .

Engaging stakeholders and addressing claims, especially those of the people most affected by a public health issue, in ethical analysis, is especially important and can sometimes support and strengthen the collaboration and cohesion needed for public acceptance of a decision. The ways to engage and reason with stakeholders in an ethical analysis will vary in different settings and communities, depending on community values , cohesion, and expectations, and can range from establishing an ethics board for deliberation, to gathering information from focus groups or social media, to including stakeholder representatives on the decision-making team. Stakeholder norms and claims are a critical feature for an ethical analysis in order to achieve a primary goal in public health—the development and maintenance of relationships of trust , defined in a report from IOM as “the belief that those with whom one interacts will take one’s interests into account, even in situations in which one is not in a position to recognize, evaluate, or thwart a potentially negative course of action by those trusted” (IOM 1996).

Ethical analysis is a dynamic process and, particularly for the practice of public health, is best accomplished through group deliberations that involve understanding others’ perspectives and thinking independently and imaginatively. Public health professionals often have to decide how best to realize numerous important societal norms and values when pursuing public health goals. Ethical tensions do occur in public health and at times require overriding an important principle , value, or moral consideration to undertake a justifiable public health action. However, a structured ethical analysis can often lead to imaginative alternatives that transcend or minimize ethical tensions and to decisions that most or many stakeholders find acceptable.