Public Health Ethics: Mapping the Terrain
Article first published online: 24 JAN 2007
The Journal of Law, Medicine & Ethics
Volume 30, Issue 2, pages 170–178, June 2002
How to Cite
Childress, J. F., Faden, R. R., Gaare, R. D., Gostin, L. O., Kahn, J., Bonnie, R. J., Kass, N. E., Mastroianni, A. C., Moreno, J. D. and Nieburg, P. (2002), Public Health Ethics: Mapping the Terrain. The Journal of Law, Medicine & Ethics, 30: 170–178. doi: 10.1111/j.1748-720X.2002.tb00384.x
- Issue published online: 24 JAN 2007
- Article first published online: 24 JAN 2007
- 1Our definition builds on the definition of health systems offered by the World Health Organization: Health systems include “all the activities whose primary purpose is to promote, restore, or maintain health.” See World Health Report 2000 Health Systems: Improving Performance ( Geneva : World Health Organization, 2000): at 5.
- 2Committee for the Study of the Future of Public Health, Division of Health Care Services, Institute of Medicine, The Future of Public Health ( Washington , D.C. : National Academy Press, 1988): at 1.
- 3We recognize that there are different views about the ultimate moral justification for the social institution of public health. For example, some communitarians appear to support public health as an instrumental goal to achieve community. Others may take the view that the state has a duty to ensure the public' s health as a matter of social justice. Although these different interpretations and others are very important for some purposes, they do not seriously affect the conception of public health ethics that we are developing, as long as public health agents identify and inform others of their various goals.
- 4Public Health Law: Power, Duty, Restraint ( Berkeley : University of California Press; New York: The Milbank Memorial Fund, 2000): at 20.,
- 5R.E.Bulger, E.M.Bobby, and H.VFineberg, eds., Committee on the Social and Ethical Impacts of Developments in Biomedicine, Division of Health Sciences Policy, Institute of Medicine, Society' s Choices: Social and Ethical Decision Making in Biomedicine ( Washington , D.C. : National Academy Press, 1995): 201–14., “Moral Epistemology,” in
- 6For some other approaches, see Ethics and the Practice of Public Health,” in R.A.Goodman et al., eds., Law in Public Health Practice ( New York : Oxford University Press, in press), and N.E. Kass, “An Ethics Framework for Public Health,”American Journal of Public Health, 91 (2001): 1776–82., , and , “
- 7We do not explore here the overlaps among public health ethics, medical ethics, research ethics, and public policy ethics, although some areas of overlap and difference will be evident throughout the discussion. Further work is needed to address some public health activities that fall within overlapping areas — for instance, surveillance, outbreak investigations, and community-based interventions may sometimes raise issues in the ethics of research involving human subjects.
- 8Recognizing universalizability by attending to past precedents and possible future precedents does not preclude a variety of experiments, for instance, to determine the best ways to protect the public' s health. Thus, it is not inappropriate for different states, in our federalist system, to try different approaches, as long as each of them is morally acceptable.
- 9This justificatory condition is probably the most controversial. Some of the authors of this paper believe that the language of “necessity” is too strong. Whatever language is used, the point is to avoid a purely utilitarian strategy that accepts only the first two conditions of effectiveness and proportionality and to ensure that the non-utilitarian general moral considerations set some prima facie limits and constraints and establish moral priorities, ceteris paribus..
- 10For another version of these justificatory conditions, see Principles of Biomedical Ethics, 5th ed. ( New York : Oxford University Press, 2001):at 19–21. We observe that some of these justificatory conditions are quite similar to the justificatory conditions that must be met in U.S. constitutional law when there is strict scrutiny because, for instance, a fundamental liberty is at stake. In such cases, the government must demonstrate that it has a “compelling interest,” that its methods are strictly necessary to achieve its objectives, and that it has adopted the “least restrictive alternative.” See Gostin, supra note 4, at 80–81.and ,
- 11Of course, this chart is oversimplified, particularly in identifying only voluntary and mandatory options. For a fuller discussion, see Warrants for Screening Programs: Public Health, Legal and Ethical Frameworks”, in R.Faden, G.Geller, and M.Powers, eds., AIDS, Women and the Next Generation ( New York : Oxford University Press, 1991): 3–26., , and , “
- 13See, and , supra note 11; Gostin, supra note 4, at 199–201.
- 14In rare cases, it may be ethically justifiable to limit the disclosure of some information for a period of time (for example, when there are serious concerns about national security, about the interpretation, certainty, or reliability of public health data; or about the potential negative effects of disclosing the information, such as with suicide clusters).
- 16P.C.Stern and H.V.Fineberg, eds., Committee on Risk Characterization, Commission on Behavioral and Social Sciences and Education, National Research Council, Understanding Risk: Informing Decisions in a Democratic Society ( Washington , D.C. : National Academy Press, 1996): at 155.
- 17Id. at 16–17, 156.
- 19On Liberty, ed. G.Himmelfarb ( Harmondsworth , England : Penguin Books, 1976): at 71. For this chart, see J.F. Childress, Who Should Decide' Paternalism in Health Care (New York: Oxford University Press, 1982): at 193.,
- 20See, for example, the discussion in I.Kawachi, B.P.Kennedy, and R.G.Wilkinson, eds., Income Inequality and Health, vol. 1 of The Society and Population Health Reader ( New York : The New Press, 2000).
- 21Medicine and Public Health, Ethics and Human Rights,” The Hastings Center Report, 27 (MayJune 1997): 6–13, at 11–12. Contrast Gostin, supra note 4, at 21. For a fuller analysis and assessment of Mann' s work, see L.O. Gostin, “Public Health, Ethics, and Human Rights: A Tribute to the Late Jonathan Mann,” S.P. Marks, “Jonathan Mann' s Legacy to the 21st Century. The Human Rights Imperative for Public Health,” and L.O. Gostin, “A Vision of Health and Human Rights for the 21st Century: A Continuing Discussion with Stephen P. Marks,”Journal of Law, Medicine, and Ethics, 29, no. 2 (2001): 121–40., “
- 23See Gostin, supra note 4, at 21.