The emerging field of public health ethics

Abstract

What do the following have in common: poverty, war, disease, privacy, human rights, medical research, torture, abortion, justice, resource allocation, social insurance, investments, infectious disease, pandemics, and clean water? If you answered “They are all issues faced by contemporary global public health” then you are ready to read editor Michael Boylan's new book, International Public Health Policy and Ethics, which contains chapters on all of these topics. This list expresses an expansive view of the realm of global public health, but is by no means exhaustive. Others would add such topics as bioterrorism, synthetic biology, food production, climate change, biodiversity, racism, and sexism. Of course, it is also worth observing that the original list can easily be encompassed under the rubric of bioethics as well, especially as that term is taken to include what Michel Foucault termed “biopolitics”.Bioethics began with medical ethics (the ethics of the doctor–patient relationship), but quickly expanded from this core to encompass all medical and scientific research on human beings, and now enfolds all life sciences work aimed at improving the health and longevity of individuals. There is even a countermovement to subdivide the ethics of the life sciences into specialised branches, such as genethics, nanoethics, neuroethics, and even synthetic ethics. The public health ethics question is more straightforward: should government interventions directed at improving the health of populations, and concerned primarily with prevention rather than treatment, be added to the seemingly borderless realm of bioethics, or do we need a new field, tentatively termed “public health ethics”, to deal with the ethical aspects of the health-related actions of governments? One argument for separation is that the two fields seem to be based on two different ethical principles: autonomy and beneficence. The argument for merger is that it may be more fruitful to reconcile and unite these fields (both of which are based on promoting human wellbeing), building them both on a single ethical foundation, such as human rights or social justice.International Public Health Policy and Ethics is a useful resource in this as yet unresolved debate. This is Boylan's second collection on this topic and is more focused on public health policy than public health ethics or even bioethics. Boylan makes no real attempt to define ethics; instead, he seems to view ethics as one important aspect of public health policy formulation. He is not alone in this view. A 2007 report by the UK's Nuffield Council on Bioethics, Public Health: Ethical Issues, for example, argues that the field is public health, and ethics is one of the factors to be taken into account by legislators in advocating for the enactment of specific public health laws, and by government officials in enforcing these laws and defining public health policies.My colleague, the late Jonathan Mann, famously argued that (public) health and human rights are “inextricably linked”. Most of the contributors in this collection seem to agree, and in her chapter Kristen Hessler seeks to expand Mann's insight that although ethics is the proper language of medicine, human rights is the proper language for public health. Hessler examines the objections to Mann's position. She argues that at least some objections are the result of the failure of the health and human rights movement to “engage with the philosophical foundations of human rights”, and to distinguish its philosophical foundations from its instrumental use in positive international law. She concludes that Mann is correct to see human wellbeing at the core of both public health and human rights, but that Mann's observation requires much more analysis of the philosophical foundations of moral human rights before it can be effectively deployed to enhance public health, especially the “right to health”.Hessler's chapter should be required reading for anyone interested in or involved in global public health. It can also be usefully contrasted to the overall thesis of Madison Powers and Ruth Faden's Social Justice: The Moral Foundations of Public Health and Health Policy (2007), which makes a strong argument for using concepts of social justice (rather than human rights) to construct the moral foundations of public health. Whether social justice or human rights provide the proper foundations of public health ultimately depends on whether one thinks such a choice must be made, and this in turn depends on identifying, as Hessler argues, the moral foundations of human rights and comparing them with the moral foundations of social justice.My own view is that just as health and human rights are complementary and synergistic, so are human rights and social justice (and so are bioethics and public health ethics for that matter). This means it is not a fruitful exercise to attempt to choose one foundation over the other to aid us in working to improve the public's health. A similar analysis applies to public health in action. Arguments that we must trade off civil liberties for public health protection in epidemics, for example, mis-state both the public health problem and its solution. The problem is the spread and deadliness of the agent causing an epidemic, not that people have too many human rights. Similarly, the public health approach to epidemics should be focused on engaging good science and epidemiology, not arbitrary police or military force against citizens, both sick and well. Effective public health action must promote public trust, not instil public fear.Other noteworthy chapters in Boylan's eclectic collection are Wanda Teays on “Torture and Public Health”, (yes, public health does now sadly encompass torture, and even after we develop more effective ways to prevent it, we must still treat its victims and prosecute its perpetrators) and Laura Purdy on “Exporting the ‘Culture of Life’” (a fancy term for the anti-abortion movement). Another chapter that makes a strong argument that “TB Matters More” (than other diseases, including HIV/AIDS) to the world's population, and so should be the subject of not just more medical resources and research, but more bioethics analysis as well, is also excellent, as is Boylan's own concluding chapter on “Clean Water”. There is much to disagree with in this book, but that's the point. The emerging field of public health ethics, if it is to exist at all, is in its infancy, and this book provides a valuable resource to provoke discussion, research, and analysis. What do the following have in common: poverty, war, disease, privacy, human rights, medical research, torture, abortion, justice, resource allocation, social insurance, investments, infectious disease, pandemics, and clean water? If you answered “They are all issues faced by contemporary global public health” then you are ready to read editor Michael Boylan's new book, International Public Health Policy and Ethics, which contains chapters on all of these topics. This list expresses an expansive view of the realm of global public health, but is by no means exhaustive. Others would add such topics as bioterrorism, synthetic biology, food production, climate change, biodiversity, racism, and sexism. Of course, it is also worth observing that the original list can easily be encompassed under the rubric of bioethics as well, especially as that term is taken to include what Michel Foucault termed “biopolitics”. Bioethics began with medical ethics (the ethics of the doctor–patient relationship), but quickly expanded from this core to encompass all medical and scientific research on human beings, and now enfolds all life sciences work aimed at improving the health and longevity of individuals. There is even a countermovement to subdivide the ethics of the life sciences into specialised branches, such as genethics, nanoethics, neuroethics, and even synthetic ethics. The public health ethics question is more straightforward: should government interventions directed at improving the health of populations, and concerned primarily with prevention rather than treatment, be added to the seemingly borderless realm of bioethics, or do we need a new field, tentatively termed “public health ethics”, to deal with the ethical aspects of the health-related actions of governments? One argument for separation is that the two fields seem to be based on two different ethical principles: autonomy and beneficence. The argument for merger is that it may be more fruitful to reconcile and unite these fields (both of which are based on promoting human wellbeing), building them both on a single ethical foundation, such as human rights or social justice. International Public Health Policy and Ethics is a useful resource in this as yet unresolved debate. This is Boylan's second collection on this topic and is more focused on public health policy than public health ethics or even bioethics. Boylan makes no real attempt to define ethics; instead, he seems to view ethics as one important aspect of public health policy formulation. He is not alone in this view. A 2007 report by the UK's Nuffield Council on Bioethics, Public Health: Ethical Issues, for example, argues that the field is public health, and ethics is one of the factors to be taken into account by legislators in advocating for the enactment of specific public health laws, and by government officials in enforcing these laws and defining public health policies. My colleague, the late Jonathan Mann, famously argued that (public) health and human rights are “inextricably linked”. Most of the contributors in this collection seem to agree, and in her chapter Kristen Hessler seeks to expand Mann's insight that although ethics is the proper language of medicine, human rights is the proper language for public health. Hessler examines the objections to Mann's position. She argues that at least some objections are the result of the failure of the health and human rights movement to “engage with the philosophical foundations of human rights”, and to distinguish its philosophical foundations from its instrumental use in positive international law. She concludes that Mann is correct to see human wellbeing at the core of both public health and human rights, but that Mann's observation requires much more analysis of the philosophical foundations of moral human rights before it can be effectively deployed to enhance public health, especially the “right to health”. Hessler's chapter should be required reading for anyone interested in or involved in global public health. It can also be usefully contrasted to the overall thesis of Madison Powers and Ruth Faden's Social Justice: The Moral Foundations of Public Health and Health Policy (2007), which makes a strong argument for using concepts of social justice (rather than human rights) to construct the moral foundations of public health. Whether social justice or human rights provide the proper foundations of public health ultimately depends on whether one thinks such a choice must be made, and this in turn depends on identifying, as Hessler argues, the moral foundations of human rights and comparing them with the moral foundations of social justice. My own view is that just as health and human rights are complementary and synergistic, so are human rights and social justice (and so are bioethics and public health ethics for that matter). This means it is not a fruitful exercise to attempt to choose one foundation over the other to aid us in working to improve the public's health. A similar analysis applies to public health in action. Arguments that we must trade off civil liberties for public health protection in epidemics, for example, mis-state both the public health problem and its solution. The problem is the spread and deadliness of the agent causing an epidemic, not that people have too many human rights. Similarly, the public health approach to epidemics should be focused on engaging good science and epidemiology, not arbitrary police or military force against citizens, both sick and well. Effective public health action must promote public trust, not instil public fear. Other noteworthy chapters in Boylan's eclectic collection are Wanda Teays on “Torture and Public Health”, (yes, public health does now sadly encompass torture, and even after we develop more effective ways to prevent it, we must still treat its victims and prosecute its perpetrators) and Laura Purdy on “Exporting the ‘Culture of Life’” (a fancy term for the anti-abortion movement). Another chapter that makes a strong argument that “TB Matters More” (than other diseases, including HIV/AIDS) to the world's population, and so should be the subject of not just more medical resources and research, but more bioethics analysis as well, is also excellent, as is Boylan's own concluding chapter on “Clean Water”. There is much to disagree with in this book, but that's the point. The emerging field of public health ethics, if it is to exist at all, is in its infancy, and this book provides a valuable resource to provoke discussion, research, and analysis.