The emerging field of public health ethics

The Ethics of Public Health

LANGUAGE NOTE | Document text in English ; abstract also in Chinese. 本文介紹生物倫理學與公共健康倫理學領域，並描述兩者之間的關係；文章尾聲將展望公共健康倫理學論未來既廣泛又多變的方向。本文首先簡介公共健康倫理學的本質，以及如何把其與比之更廣闊的生物倫理學作出區分，因此需要提出公共健康倫理學的定義，以助釐清公共健康倫理的重點。隨後，本文簡述公共健康倫理學文獻的一些最新進展，包括圍繞新冠病毒、大流行病、抗菌素抗藥性、「生活方式」疾病及正義等道德問題。本文同時論及就干預公共健康的「合法範圍」所提出的觀點之間於政治及形而上學的角力。其後本文探討公共健康倫理學所面臨的挑戰，包括其複雜又多元的性質。而且公共健康實踐高度政治化，其政治化的原因是因為公共健康影響整個人口及社區，而很多關於公共健康的決策由政治人物而非公共健康專家所作出。此外，公共健康倫理也因為公共健康的範圍擴展至納入非政府公共健康行動者而面臨進一步的挑戰。本文最後闡述有關公共健康的一些未來方向，包括「公共健康觀」的出現，以作為為人熟知的健康與社會問題的形而上學框架、把該領域的認知和道德基礎去殖民化以涵蓋更廣泛的知識，以及一些包括美德在内的公共健康倫理學的理論發展。筆者建議讀者把文章視為對公共健康倫理學領域的一部分介紹，並鼓勵他們閲讀本文所引用的論文，並以這些論文作為進入所涵蓋主題的大量文獻之門徑。公共健康倫理學是一個相對年輕的領域，而該領域有著巨大的成長及發掘更多新概念的潛力。 This essay begins by introducing the fields of bioethics and public health ethics and describing the relationship between them. It ends with some glimpses into the wide-ranging and discourse-changing directions of the literature on public health ethics. To open, the paper describes the field of public health ethics and how it is differentiated from the wider field of bioethics. This requires a brief description of public health to clarify the nature of public health ethics. The essay then provides a brief overview of a few recent developments in the public health ethics literature, including the moral issues raised by COVID-19 and pandemics, anti-microbial resistance, ‘lifestyle’ diseases and justice. The paper also touches on the political and metaphysical tensions in views on what counts as a ‘legitimate area’ of intervention for public health. The essay then turns to a couple of challenges in the field of public health ethics, specifically the complex and multi-disciplinary nature of the field and the fact that public health practice is a highly political area. Public health is political both in the sense that it affects entire populations or communities and in the sense that many decisions about public health are made by politicians rather than public health experts. A further challenge to public health ethics is the question of what counts as ‘public health’, as the scope has been broadened to include non-governmental public health actors. Finally, the essay describes some future directions for research in public health ethics, including ‘public health view’ becoming a metaphysical framing for familiar health and social issues and decolonising the epistemic and moral foundations of the field to include a wider set of knowledge sources and values. There are also some theoretical developments that integrate virtue into public health ethics. The reader should take this essay as a partial introduction to the field, and they are highly encouraged to read the papers that are cited here and to use those papers as a gateway into the large literature on the topics covered. Public health ethics is a relatively young field, with an enormous potential for growth and new ideas.

Solidarity is a concept increasingly employed in bioethics whose application merits further clarity and explanation. Given how vital cooperation and community-level care are to mitigating communicable disease transmission, we use lessons from the COVID-19 pandemic to reveal how solidarity is a useful descriptive and analytical tool for public health scholars, practitioners, and policymakers. Drawing upon an influential framework of solidarity that highlights how solidarity arises from the ground up, we reveal how structural forces can impact the cultivation of solidarity from the top down, particularly through ensuring robust access to important social determinants of health. Public health institutions can support solidarity movements among individuals and communities by adopting a lens of social justice when considering public health priorities and, in turn, promote health equity.

. Nixon S. & Forman L. ( 2008 ) , 8 , 2 . DOI: 10.1186/1472‐698X‐8‐2 . Background The fields of human rights and public health ethics are each concerned with promoting health and elucidating norms for action. To date, however, little has been written about the contribution that these two justificatory frameworks can make together. This paper explores how a combined approach may make a more comprehensive contribution to resolving normative health issues and to advancing a normative framework for global health action than either approach made alone. We explore this synergy by first providing overviews of public health ethics and of international human rights law relevant to health and, second, by articulating complementarities between human rights and public health ethics.Discussion We argue that public health ethics can contribute to human rights by: (i) reinforcing the normative claims of international human rights law; (ii) strengthening advocacy for human rights; and (iii) bridging the divide between public health practitioners and human rights advocates in certain contemporary health domains. We then discuss how human rights can contribute to public health ethics by contributing to discourses on the determinants of health through: (i) definitions of the right to health and the notion of the indivisibility of rights; (ii) emphasis on the duties of states to progressively realize the health of citizens; and (iii) recognition of the protection of human rights as itself a determinant of health. We also discuss the role that human rights can play for the emergent field of public health ethics by refocusing attention on the health and illness on marginalized individuals and populations.Summary Actors within the fields of public health, ethics and human rights can gain analytic tools by embracing the untapped potential for collaboration inherent in such a combined approach.

BackgroundThe fields of human rights and public health ethics are each concerned with promoting health and elucidating norms for action. To date, however, little has been written about the contribution that these two justificatory frameworks can make together. This article explores how a combined approach may make a more comprehensive contribution to resolving normative health issues and to advancing a normative framework for global health action than either approach made alone. We explore this synergy by first providing overviews of public health ethics and of international human rights law relevant to health and, second, by articulating complementarities between human rights and public health ethics.DiscussionWe argue that public health ethics can contribute to human rights by: (a) reinforcing the normative claims of international human rights law, (b) strengthening advocacy for human rights, and (c) bridging the divide between public health practitioners and human rights advocates in certain contemporary health domains. We then discuss how human rights can contribute to public health ethics by contributing to discourses on the determinants of health through: (a) definitions of the right to health and the notion of the indivisibility of rights, (b) emphasis on the duties of states to progressively realize the health of citizens, and (c) recognition of the protection of human rights as itself a determinant of health. We also discuss the role that human rights can play for the emergent field of public health ethics by refocusing attention on the health and illness on marginalized individuals and populations.SummaryActors within the fields of public health, ethics and human rights can gain analytic tools by embracing the untapped potential for collaboration inherent in such a combined approach.

Jaffe and Hope provide an insightful analysis of the ethics implicit in public health interventions. According to them, public health interventions are traditionally divided into two categories: (i) interventions that are beneficial to the recipients [and wider society] (for example, vaccinations); and (ii) interventions that are required to prevent such serious harm to the general population that coercive measures by the state is justified and regulated through public health law (for example, isolation and quarantine). Using the proposed provision of anti-retroviral treatment to all HIV-infected individuals, regardless of the degree of their immune suppression, as proposed by Granich et al. (2009), as an example, Jaffe and Hope argue that such a measure constitutes a third category of public health interventions (hereinafter referred to as ‘category 3′ public health interventions) as they are neither unequivocally in the best interests of the recipients nor given within a clear legal framework designed for imposing restrictions on individuals who are a danger to public health. In addressing the issue of whether there are any widely accepted ethical models within medicine that allow some people to be given an intervention that, on balance, risks more harm than good for the sake of benefit to others (i.e., category 3 measures), Jaffe and Hope argue that ‘the ethical framework and standards that have been, and continue to be, developed in the context of medical research provide a useful model for public health’, and base their proposed ethical framework, thereon. In their view, category 3 public health interventions can ethically proceed if they meet six “necessary conditions”. While Jaffe and Hope’s proposed framework is a welcome addition to the relatively nascent field of public health ethics, it is not clear why they omitted alluding to, and appraising the appropriateness of, pioneering public health ethics frameworks, such as those proposed in the last decade by Kass (2001), Childress et al (2002), Upshur (2002), and Gostin (2003), in relation to category 3 public health interventions / measures. Although they cite Gostin’s 2002 seminal work on public health law, their inexplicable omission to discuss existing public health ethics frameworks gives the impression that Jaffe and Hope are either unaware of the existence of such proposed frameworks (which seems unlikely), or that they believe that such frameworks are inappropriate evaluative models for category 3 public health measures. The latter would be puzzling given the apparent similarities between all the proposed frameworks, to date, theirs included. If they believe the latter is applicable, the onus was/is on Jaffe and Hope to adduce relevant arguments to justify why this is so. Otherwise they risk seemingly reinventing the wheel. While there are distinct differences between Jaffe and Hope’s framework and those that preceded it (for example, none of the earlier public health ethics frameworks regards an informed consent process as a necessary condition to implementing a public health measure), there are striking similarities too. For example, Jaffe and Hope’s third necessary condition (the public health benefit cannot be produced by an alternative means that is ethically preferable) is akin to Childress et al.’s Least Infringement principle, Kass’ Burden Minimisation / Alternative Approaches principle, and Upshur’s Least Restrictive or Coercive Means principle. Similarly, Jaffe and Hope’s fourth proposed necessary condition (the public health benefit is such as to justify the risk of harm to participants) is akin to Childress et al’s Necessity principle, Kass and Gostin’s respective Effectiveness principles, and Upshur’s Harm principle. Likewise, Jaffe and Hope’s sixth necessary condition (the public health measure is scrutinized by some properly constituted and appropriate independent body) is akin to Childress et al’s Public Justification principle, Kass’ notion of procedural justice outlined in her principle of fair balancing of burdens and benefits, and similar in sentiment to Upshur’s Transparency principle (although all three latter frameworks also differ in that they do not make reference to Norm Daniel’s Accountability for Reasonableness model). Given these overall similarities, it is not clear if / how Jaffe and Hope’s proposed “necessary conditions” differ, or are meant to differ, from the proposed “principles” enunciated in proposed frameworks of Kass, Childress et al, Upshur, and Gostin. Arguing that there is a distinction between a “necessary condition” and a “principle” is unsustainable as the latter could easily be phrased as a “necessary condition”. For example, Upshur’s proposed public health ethics framework posits the principle of Reciprocity (which has no parallel in Jaffe and Hope’s model, although it would be very useful if incorporated). Rebranded as a “necessary condition” could see the principle of Reciprocity phrased as follows: “Those affected by a proposed intervention/measure should be adequately compensated and/or offered viable alternative interventions of equal or superior efficacy, if such alternate interventions exist”. Using Granich et al’s HIV treatment proposal as an example, the principle of Reciprocity would require public health authorities to prospectively put in place mechanisms that ensure that recipients who have adverse reaction to first-line ARVS are immediately switched to second-line therapies, at state expense. Furthermore, those who experience severe adverse reactions as a result of their treatment regimen must be fairly compensated. While Jaffe and Hope’s proposed framework is a valuable addition to current literature on public health ethics, it would be helpful to see a follow-up manuscript from them wherein they reconcile or distinguish their proposed public health ethics framework with/from those that have preceded it. This will strengthen not just their proposed framework, but also the field of public health ethics.

A Public Health Reset Through Contractualism

Introducing public health ethics poses two special challenges. First, it is a relatively new field that combines public health and practical ethics. Its unfamiliarity requires considerable explanation, yet its scope and emergent qualities make delineation difficult. Moreover, while the early development of public health ethics occurred in a western context, its reach, like public health itself, has become global. A second challenge, then, is to articulate an approach specific enough to provide clear guidance yet sufficiently flexible and encompassing to adapt to global contexts. Broadly speaking, public health ethics helps guide practical decisions affecting population or community health based on scientific evidence and in accordance with accepted values and standards of right and wrong. In these ways, public health ethics builds on its parent disciplines of public health and ethics. This dual inheritance plays out in the definition the U.S. Centers for Disease Control and Prevention (CDC) offers of public health ethics: “A systematic process to clarify, prioritize, and justify possible courses of public health action based on ethical principles, values and beliefs of stakeholders, and scientific and other information” (CDC 2011). Public health ethics shares with other fields of practical and professional ethics both the general theories of ethics and a common store of ethical principles, values, and beliefs. It differs from these other fields largely in the nature of challenges that public health officials typically encounter and in the ethical frameworks it employs to address these challenges. Frameworks provide methodical approaches or procedures that tailor general ethical theories, principles, values, and beliefs to the specific ethical challenges that arise in a particular field. Although no framework is definitive, many are useful, and some are especially effective in particular contexts. This chapter will conclude by setting forth a straightforward, stepwise ethics framework that provides a tool for analyzing the cases in this volume and, more importantly, one that public health practitioners have found useful in a range of contexts. For a public health practitioner, knowing how to employ an ethics framework to address a range of ethical challenges in public health—a know-how that depends on practice—is the ultimate take-home message.

"This article asks the difficult questions- what is public health? and what is public health ethics? The article also recognizes that even though public health and biomedical ethics overlap, they have distinct aspects. The article examines the unique population-based perspective of public health and how it can be distinguished from patientcentered biomedical ethics. Additionally, public health scholars and practitioners often use ethical analyses with other forms of reasoning, particularly law and human rights. The article, therefore, explores the relationship among public health ethics, public health law and human rights. The various meanings of each form of reasoning are discussed, as well as the similarities and differences among them. The article concludes with a proposal for reconciling the inherent tradeoffs between public health and civil liberties. Prior to exercising compulsory powers, public health officials should examine the risk to the public; the likelihood that the intervention will be effective; the opportunity costs; the burdens on human rights and the policy`s fairness."

The SARS-CoV-2 (COVID-19) pandemic has caused social and economic devastation. As the milestone of two years of ‘living with the virus’ approaches, governments and businesses are attempting to develop means of reopening society whilst still protecting public health. However, developing interventions – particularly technological interventions – that find a safe, socially acceptable, and ethically justifiable balance between these two seemingly opposing demands is extremely challenging. There is no one right solution, but the current most popular ‘solution’ is the so-called ‘COVID-19 Vaccine Passport’ (also known as COVID-19 passes or certificates), the use of which may be supported by both human rights and international public health law if they are designed and implemented appropriately. (We use the term ‘Vaccine Passport’ because it has been adopted by the popular press. Though it has been used in many ways, here we use it generically to refer to a document that certifies that an individual has been vaccinated against COVID-19 and on that basis grants the bearer more liberties than to those who have not been vaccinated. Later, we will discuss why it is necessary to move beyond considering only vaccinations, which informs our preferred term of ‘COVID-19 Status Pass’.) We set out to answer the following questions: how should governments and businesses assess the risks in light of human rights, public health ethics, and digital ethics concerns which emerge from developing and deploying COVID-19 Vaccine Passports? What design decisions should businesses make when developing COVID-19 Vaccine Passports to help ensure they respect human rights, and both public health and digital ethics? Do the implications for human rights, public health, and digital ethics vary depending on where and when COVID-19 Vaccine Passports are used? What are the rights and powers of the individual to object to or seek remedy for the use of COVID-19 Vaccine Passports? How can the risks of inequalities and social division derived from the deployment of COVID-19 Vaccine Passports be avoided or mitigated? We conducted a literature review and documentary analysis, supplementing our findings with news articles where appropriate. The following pages report our results, concluding with a series of actionable recommendations for businesses, national governments, and supranational organisations.

Public health ethics is a discipline dealing with ethical issues relating to public health. As a branch of medical ethics, it also deals with clinical and research ethics. The core issue of public health ethics is to balance the conflict between individual liberty and the public good. Because of the coronavirus disease 2019 (COVID-19) pandemic, deliberation based on public health ethics is required to reduce social disparities and increase community cohesion. This study presents three public health ethics challenges. The first is to introduce an egalitarian liberal approach to public health concerning social and economic issues experienced by vulnerable populations both domestically and globally. I then propose alternative and compensatory public health policies that serve the principles of justice. Second, public health ethics must ensure procedural justice in all public health policy decisions. For example, when deciding to implement public health policies, including restrictions on individual liberties, the decision making process must be open to the public. Third, citizens and students must be educated on public health ethics. The public must be provided with an open forum to deliberate on ethical issues related to public health as well as the appropriate training to do so.

Public Health Policy and Ethics brings together philosophers and practitioners to address the foundations and principles upon which public health policy may be advanced. What is the basis that justifies public health in the first place? Why should individuals be disadvantaged for the sake of the group? How do policy concerns and clinical practice work together and work against each other? Can the boundaries of public health be extended to include social ills that are amenable to group-dynamic solutions? These are some of the crucial questions that form the core of this volume of original essays sure to cause practitioners to engage in a critical re-evaluation of the role of ethics in public health policy. This volume is unique because of its philosophical approach. It develops a theoretical basis for public health and then examines cutting-edge issues of practice that include social and political issues of public health. In this way the book extends the usual purview of public health. Public Health Policy and Ethics is of interest to those working in public health policy, ethics and social philosophy. It may be used as a textbook for courses on public health policy and ethics, medical ethics, social philosophy and applied or public philosophy.

What makes something a human right? What is the relationship between the moral foundations of human rights and human rights law? What are the difficulties of appealing to human rights? This book offers a survey of current thinking on the philosophical foundations of human rights. Divided into four parts, this book focuses first on the moral grounds of human rights, for example in our dignity, agency, interests or needs. Secondly, it looks at the reciprocal relationship between the moral groundings of human rights and the law and politics of human rights. Thirdly, it discusses specific and topical human rights including freedom of expression and religion, security, and health, and more controversial rights such as a human right to subsistence. The final part discusses nuanced critical and reformative views on human rights from feminist, Kantian, and relativist perspectives among others. The chapters represent new and canonical research. Each section comprises of a set of arguments and replies, offering an analysis of different positions within the debate in question, with an introduction to help with navigating the diversity of views on the philosophical foundations of human rights.

Public health ethics, as distinct from clinical/medical bioethics, is an emerging field of study in academic settings. As part of a larger effort to address what the conceptual and content boundaries of this field are, or ought to be, a group at the University of Toronto hosted an international working symposium to discuss and outline a research agenda for public health ethics. The symposium, which took place in May 2002, was organized into four major areas of ethical concern central to public health: individual rights and the common good; risk and precaution; surveillance and regulation; and social justice and global health equity. This paper will provide an overview of some of the main themes and issues that emerged from the key papers that were developed from the symposium and discuss their importance in the emerging field of public health ethics. Significant issues were identified, such as the importance of distinguishing public health ethics from traditional bioethics; the development of the notion of common interests; broad definitions of public health, that include upstream sources of health inequities, and an understanding of the theoretical landscape from which public health ethics has emerged.

Foundation and Continuation of Public Health ReviewsPublic Health Reviews (PHR) was founded in 1972 in Israel and published for over 30 years, with listing in Pubmed, Medline and Index Medicus and many other on-line data bases until the owner retired. The journal was purchased in 2010 by the EHESP (Ecole des Hautes Etudes en Sante Publique, the French National School of public health) and established with a distinguished international Editorial Board.The mission of PHR since 2010 has been to provide access to European and global public health students, teachers, researchers, practitioners and policy makers of theme topic reviews of high quality to promote learning and discussion of issues in public health from a multi disciplinary point of view. The Editorial Board participated actively in policy development and leadership of many of the theme issues that evolved. PHR strives to bring topical reviews to promote translation of evidence and science into applied public health policy and practice, including the evolution of health systems as part of public health spectrum [1].The theme topics PHR issues during 2010-2013 included:*The New Public Health*Ageing Societies*Public Health Education*Cardiovascular Disease*Ethics in Public Health*Mental Health as a Public Health Issue*Towards a Healthier 2020, and*Substance Use Issues: New Insights.The New Home for Public Health Reviews 2014In 2014, a further reformation of PHR was arranged with affiliation and sponsorship by the Association of Schools of Public Health in the European Region (ASPHER), along with continued sponsorship by EHESP, and an additional sponsor, a Swiss School of public health. An agreement was signed with Biomed Central to publish PHR as an online open access journal. The new arrangements for sponsorship and operation of PHR provided for the continued mission of each issue addressing concepts such as health disparities, social determinants of health, demographic shifts and changing patterns of health needs, education of the public health workforce and policy makers, and healthcare delivery systems. [1].A new Editorial Board (EB) was organized with a strengthened European, international and multi-disciplinary composition to continue the excellent work of the previous EB. A core group of ASPHER representatives working with the editorial team provided important support over the transition period. The previous policies of theme issues will be augmented by accepting individually submitted review papers which fit in with topical issues. PHR will strive to achieve monthly issues, yielding 30 articles annually, with free for online access, including archived previous volumes.The Opening Issue of PHR in 2015The initial issue is a follow up to the 2012 volume on public health ethics. A second issue of PHR on this theme within four years of a previous issue is based on the initiative of ASPHER to prepare curriculum material for formal and informal teaching of public health ethics in the European context as explained in the Lee and Royo-Bordonada editorial [2], and Towards Public Health Ethics [3]. A European oriented curriculum will need relevant case studies for the organized teaching of ethics in public health education programs for undergraduate and graduate degree programs in Europe, in parallel to current Canadian and U.S. initiatives in public health ethics case studies [4].Public health has many enormous achievements to its credit adding many years of life expectancy globally. But public health has also suffered from past ethical failures of staggering proportions in the 20th century through association with eugenics. The most egregious of these was the active and passive participation of medical and public health professionals in interpretations of eugenics which led to mass sterilization and the murder of handicapped people, and participation in the Holocaust perpetrated by Nazi Germany. …