Academic journal article Public Health Reviews; Rennes

Guest Editorial: Public Health Ethics Theory: Review and Path to Convergence

Academic journal article Public Health Reviews; Rennes

Guest Editorial: Public Health Ethics Theory: Review and Path to Convergence

Article excerpt

Reprinted with permission of the author.

Citation: Lee LM. Public health ethics theory: review and path to convergence. J Law Med Ethics. 2012;85-98.

INTRODUCTION

For over 100 years, the field of contemporary public health has existed to improve the health of communities and populations. As public health practitioners conduct their work-be it focused on preventing transmission of infectious diseases, or prevention of injury, or prevention of and cures for chronic conditions-ethical dimensions arise. Borrowing heavily from the ethical tools developed for research ethics and bioethics, the nascent field of public health ethics soon began to feel the limits of the clinical model and began creating different frameworks to guide its ethical challenges. Several public health ethics frameworks have been introduced since the late 1990s, ranging from extensions of principle-based models to human rights and social justice perspectives to those based on political philosophy. None has coalesced as the framework of choice in the discipline of public health. This paper examines several of the most-known frameworks of public health ethics for their common theoretical underpinnings and values, and suggests next steps toward the formulation of a single framework.

THE EVOLUTION OF PUBLIC HEALTH ETHICS

It is impossible to read a paper about public health ethics without seeing the now familiar dilemma that traditional theories of clinical and bioethics are not transferrable directly to public health ethics. The major difficulties in translation stem from the fundamental differences between clinical and public health practice. Most saliently, clinical medicine has at its core the patient-provider relationship, while public health has at its core the responsibility for the health of the community. Clinicians see patients they know; public health practitioners intervene upon populations of unspecified individuals.1

Other important differences exist between clinical and public health practice. Clinical medicine uses medical interventions to cure or treat existing illness, while public health practice uses primarily non-medical means (with the notable exception of immunization) such as policy and law, sanitation, the built environment, and behavioral health to prevent injury and disease and to promote health and wellness.2 In clinical medicine, a limited number of similarly clinically trained professions (e.g., physicians and nurses) deliver direct care, whereas in public health practice an increasingly diverse group of practitioners round out the effective team, including epidemiologists, statisticians, laboratorians, physicians, informaticians, economists, decision and behavioral scientists, and policymakers.3 This team produces what Marcel Verweij and Angus Dawson1 describe as a collective effort, usually via government, to bring about participation of the public. Both clinical and public health practice attend to justice, but the focus of justice in clinical medicine is usually faint and on distributive justice, or ensuring that there is enough for everyone entitled to care. In public health practice, the focus on justice emphasizes social justice,4 or rights to health care, and disparities in access and outcomes.

These characteristics differentiating clinical and public health practice lead to different ethical challenges and presumptions in the respective fields. The moral governance needed for public health did not translate directly from the principles of bioethics, as transmuted for research ethics in the 1940s and 1950s or clinical ethics in the 1960s and 1970s. In the 1980s, the early HIV/AIDS epidemic elucidated the inadequacy of clinical ethics to address pressing ethical challenges that straddled private and public life. This inadequacy led pioneering theorists such as Ronald Bayer et al.,5 Ruth Faden and Nancy Kass,6 and Lawrence Gostin and William Curran7 to discuss ways to expand bioethics in the 1980s to include public health ethical concerns. …

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