Abstract
Background
The World Health Organization and the Association of Schools of Public Health in the European Region called for the professionalization of the public health workforce, including the creation of codes of ethics. In this article, the Public Health Ethics and Law Network provides guidance on creating such codes, based on values and principles commonly identified for public health.
Methods
Our interest was in codes addressing public health broadly rather than disciplines within public health. Public Health codes of ethics are typically published on agency and organization websites rather than peer-reviewed literature. We searched several online databases, such as PubMed; United States government websites; Spanish language websites; and English language websites for public health organizations.
Results
We synthesized the principles found into 10 adjectives—such as caring, responsive, and trustworthy—with short elaborations. These terms are practical, for non-philosophers, and provide flexibility for adaptation to country contexts.
Conclusions
The creation of a code of ethics should be followed by the identification and building of ethical competencies and capacity for public health professionals and institutions. There are plans to collaborate with pilot sites in the use and generation of further learning, and additional assistance for competencies and other resources to support a code of ethics and competencies.
Keywords: ethics, public health, professionalism
Introduction
The era we live in has been marked by major public health challenges, including a lethal pandemic, ecological degradation, and climate migration. At the same time, the Great Resignation in health care has thinned the ranks of public health professionals.1 It will fall to a new generation of health professionals to guide our responses to today’s and tomorrow’s health threats. To thrive in their work, professionals need a clear sense of purpose, a supportive community of co-workers, and resources to draw upon. An important means of identifying purpose and building community is clarifying shared values. A code of ethics highlights the normative foundation of a profession and describes/specifies these values and what they mean for professional practice. Professional values are also often consistent with personal principles and values such as honesty, fairness and equity in all interpersonal, personal or professional activities, and relate to respecting the dignity, diversity and rights of individuals and groups.2 Often, these values are articulated in a code of professional ethics.3
In light of foreseeable health threats, the World Health Organization (WHO) and the Association of Schools of Public Health in the European Region (ASPHER) called for the professionalization of the public health workforce, that it may be adequately valued, recognized and supported and that it may respond quickly, effectively, and equitably to future public health threats.4 The ‘WHO-ASPHER Roadmap to Professionalizing the Public Health Workforce (PHW) in the European Region’ provides recommendations for international and national public health system-wide action on how to develop and support the professionalization of the PHW.5,6 It sets direction on how to advance regulation, structures, and solutions for a strong and resilient public health workforce to be at the forefront of European health policymaking. These recommendations are underpinned by a conceptual model that outlines the levers and measures of professionalization including (i) competencies, (ii) training and education, (iii) formal organization, (iv) professional credentialing and v) a code of ethics and professional conduct.4 The Roadmap states, ‘It is [the] collective professional approach to complex societal problems that raises the public health profile from that of an occupation concerned largely with reductive tasks … to a profession… underpinned by a consensual understanding of and commitment to values that focus on health equity.’ and highlights code of ethics as one of the key pillars for professionalization.
Our purpose here is to announce the creation of guidance for creating codes of ethics and ethics-related competencies for public health practice. The paper will focus on the background and required theory for the guidance. This included the necessary values and principles underpinning good public health practice. The principles and a section on the applicability of this guidance aids organizations who are seeking to use this work to create their own code of ethics practice. The guide has been developed by an expert working group of the Public Health Ethics and Law (PHEL) network, a coalition formed between the Global Network for Academic Public Health, ASPHER, the European Public Health Association, the UK Faculty of Public Health, and others. One author (JT) played an instrumental role in the creation of the American Public Health Code of Ethics. Others have been addressing public health ethics in other countries. Additional authors of this publication have assisted with the reviews for this article.
Literature searches
We conducted two literature searches to inform our guidance: one of the peer-reviewed literature on public health values, and another of the grey literature for public health codes of ethics. In the peer-reviewed literature we searched on PubMed and Scopus articles published since 1 January 2000 on intersections of the terms ‘public health,’ ‘ethics,’ ‘morals,’ ‘values’ and ‘social values.’ Among the 488 search results yielded with these terms, we identified 9 that addressed values in public health in its entirety.
Unlike literature on public health values, codes of ethics are seldom published in peer-reviewed literature. Rather, they are posted by public health agencies and organizations on their websites. We limited our online search to country-level codes encompassing all of public health rather than codes for components of public health such as epidemiology or health behavior. The latter tend to address ethics for the profession’s research methods.
Our online search consisted of four components: (i) Searching the Dimensions, PubMed, Policy Commons, Scopus, Homeland Security Digital Library, and ProQuest Congressional databases using English and French keyword and index terms related to codes of ethics and public health; (ii) Using Google Advanced Search to search United States government websites for the terms ‘ethics code,’ ‘standards,’ ‘guidelines’ and ‘public health’; (iii) Using Google Advanced Search to search Spanish language websites for the terms ‘código de ética’ and ‘salud pública’; (iv) Searching the English language websites of national public health organizations in the United States, the United Kingdom, Australia and New Zealand for the terms ‘code of ethics,’ ‘code,’ ‘standards’ and ‘guidelines.’ In databases, results were sorted by relevance and the top 50% or more were reviewed at the title/abstract level. For websites, the equivalent website title and text snippet provided by search engines were reviewed; ~40% of website results were reviewed in brief and 5% reviewed in full. The data underlying this article will be shared on reasonable request to the corresponding author.
Public health values
Public health ethics are sometimes conflated with public health law and medical ethics, yet they are distinct. Some ethical norms are encoded in law, but some are not. Moreover, some laws were once regarded by the ruling majority as ethical, such as legalized slavery, but have come to be viewed universally as immoral.
Medical ethics emerged in large part from abuses of researchers on study subjects in Nazi medical experiments, studies on prisoners, and on rural African–American sharecroppers. In contrast to the dynamic between two individuals—such as a researcher or clinician and a study participant—public health ethics addresses the dynamic between populations and governments. Autonomy, which is one of the pillars of medical ethics, provides an instructive example. In medical ethics, the patient can always exercise his/her autonomy by refusing a medication or procedure. In a population context, however, individuals are interdependent, interconnected, and interrelated with one another: one person’s infection is another person’s exposure, and one person’s risk puts others at risk. In the communitarian perspective of public health, the autonomy of an individual must sometimes be constrained in the interest of protecting the community. But to avoid abuses in the name of communitarianism, those advocating restriction of autonomy must demonstrate the need.7 Moreover, the restrictions should be backed by public health law.
The various disciplines within public health (e.g, health policy, epidemiology, health behavior, environmental health, etc.) have drawn from ethical schools of thought that best address particular concerns they commonly encounter. In a public health ethic that is an umbrella over the disciplines, then, there are elements of utilitarianism, deontology, human rights, virtue ethics and care ethics. There is also a growing appreciation for many indigenous peoples’ views of the centrality of land and place, and interdependencies and interconnections that include the relations between animate and inanimate objects. American Indian theologian, Vine Deloria, Jr. wrote, ‘The relationships that serve to form the unity of nature are of vastly more importance to most tribal religions.’8 In African indigenous Ubuntu philosophy, to be human is to be interdependent, interconnected and interrelated with all beings and environment, whether physical or metaphysical, through all and for all. John Mbiti captured African communitarianism in saying, ‘I am because you are, and because you are, therefore, I am’.9
Public health values have been enumerated in books10,11 peer-reviewed literature3,7,12,13,14,15,16,17,18 codes of ethics19,20 and responses to health threats such as the Covid pandemic.21 The sources are highly consistent in their identification of public health values and their recognition of moral obligations and interconnectedness of the three principal protagonists for health: individuals, institutions, and communities. These several perspectives are synthesized into the following summary, which describes what a meaningful value base to modern public health in the current era would look like.
The health of any part of nature depends on the health of all other parts. Human health does not stand apart from nature but is integrated with it. To attend to human health, then, is to attend to a balance of nature that will remain for future generations. Human thriving is the ability to live in harmony with the rest of nature.
Public health policies and programs aim to prevent the occurrence of health-threatening conditions or events by addressing their root causes, including the social determinants.
Public health, as the name suggests, concerns itself with the health of a population. A population is more than a collection of individuals. Because humans are social, they form communities: people who depend on each other, support each other, do things together, and enjoy one another. Public health addresses the health of communities and recognizes their interdependence and interconnectedness.
Although people sort themselves out into different roles in the community and hierarchies typically emerge, each person is a valuable member of the community. Each person has a right to the basic resources necessary for health and thriving, such as shelter, food, companionship, health care, and safety from abuse or harm. Those necessary resources and protections should be distributed equitably.
Because of natural interdependencies, including the sharing of both conditions and resources, public health encompasses the health of all people living within an area, regardless of their lineage or legality. Public health programs are inclusive.
Public health policies are best carried out cooperatively with the population, and when people act in solidarity with each other. Voluntary public participation stems from a high level of public trust in public health institutions and professionals. Trust is earned with policies and practices that demonstrate transparency, accountability, humility, and more. Conversely, public health policies are best received when implemented with the least amount of coercion possible and responses to health threatening events that are proportional to the size of the threat.
These values and the principles that follow apply both to institutions and the individuals who constitute them. The relevant institutions are those with a public health mission or mandate, including government ministries, public administration, agencies, and offices, as well as public-health-oriented non-governmental organizations. Since the work of institutions is carried out by individuals, the ethics in a code apply to professional staff as well as the institution as a whole. Thus, not only is a public health professional to be trustworthy, for example, but the principle of trustworthiness should permeate the policies and practices of the institution.
From values to principles and codes
Professional ethics progress from theory to practice through a number of steps: from values to principles, to codes, then a list of the competencies needed to implement the principles, and tools for training. For example, the value of earning the trust of a population is spelled out more practically in the principles of responsiveness, trustworthiness, collaboration, fairness, accountability, and communication. Such principles form the substance of a code of ethics. Good communication, just to select one principle, includes competence in presenting accurate data for professionals and lay audiences. One tool for learning how to communicate well is the US Centers for Disease Control and Prevention’s Crisis and Emergency Risk Communication manual. This cascade of steps with related documents and tools are collected in a Public Health Ethics and Law Network website.22
There is no single set of principles that applies worldwide and thus no global code of ethics. Each country has been shaped by its own history. Some European countries may give more value to constraining the power of individual states than America does, having fought two world wars on their own soil.23 In some instances, a country’s demographics may shape their distribution of scarce life-saving resources. Many African countries have a young population while European countries are more aged. African countries may thus give more priority to their elders because their cultures revere the aged and because the elders are few.24 Another example of different approaches to public health lies in national responses to the Covid pandemic. Within Europe, Scandinavian countries stood out for their variation in response, with Sweden having a relative lack of restrictions.
The authority given to a code of ethics can also vary. The American Code does not stipulate punishment for violations, but the Philippines’ Code of Conduct for Public Health Workers ends with the statement, ‘Any person who shall willfully interfere with, restrain, or coerce any public health worker in the exercise of his rights or shall commit any act violating any of the provisions in the Revised Implementing Rules and Regulations of the Magna Carta of Public Health Workers, shall be punished …If the offender is a public official, the court may impose the penalty of disqualification from office.’20
Principles for the ethical practice of public health
The Public Health Ethics and Law Network exists in part to guide countries in creating codes of public health ethics suited to their context. To accommodate the creation of a variety of codes while still drawing from commonly shared values, we enumerate principles as single word adjectives, such as caring and responsive, with accompanying explanations. The adjectives describe characteristics that inform public health actions, such as decision-making. Written in this way, they are accessible to non-philosophers and adaptable while still holding to core values. To be clear, the ten principles we list here are not intended as a code of ethics, but as guidance for the creation of one. We assert, then, that ethical public health institutions and individuals are to be:
1. Caring
They fulfill their responsibilities with empathy and compassion, protecting the rights of individuals. They appreciate the interdependencies in nature, including those with and among humans, and seek to ensure a balance that enables current and future generations of humans to thrive. They seek to prevent health risks from arising, including moral injury to public health workers, and.
2. Responsive
When there is a public health threat, they attend to it in a timely manner. And when a public health policy or practice is challenged, they listen intently to understand the concern and respond to it with respect and adaptation if need be.
3. Trustworthy
They are honest about what they know and humble about what they don’t know. They follow through on commitments or work with those to whom a commitment was made for a mutually agreeable adjustment.
4. Flexible
They accommodate differences between groups when doing so doesn’t compromise the safety of others. When they learn that a policy or program is ineffective or inadequate, they either end or adapt it to the context.
5. Collaborative
They communicate and coordinate with other agencies, organizations, and countries to address public health concerns. They collaborate with the public through public meetings, seeking the knowledge and wisdom of communities. They enable individuals, both public health professionals and the public, to work in solidarity with each other toward policies and practices that bring health and thriving.
6. Fair
They do not ask the public to do more than is necessary, and they seek an equitable distribution of benefits and burdens. They do not enact policies without conferring with those who will be affected by them.
7. Informed
They base their policies and programs on input from stakeholders and reliable data. They seek to understand the health-related context of particular places, including historical forces that shape the present.
8. Accountable
They are transparent about their processes and actions, they provide a means for the public to express their perspectives, and they learn from their mistakes.
9. Communicative
They share information that enables the public to effectively participate in the protection of interdependent health and to work in solidarity with each other.
10. Effective
They train their employees or personally learn skills that enable them to safely, effectively, efficiently, and compassionately carry out their responsibilities. They evaluate their policies and practices and share lessons learned with other institutions and professionals.
From this template, public health institutions, public health professional bodies or a country ethics committee could use the single word terms with accompanying explanations, as written here, or make them into a sentence in their own words. In meeting the principle of effectiveness, for example, one could formulate a norm as the Philippines Code of Conduct does that is compatible with the given principle: ‘[a public health worker] shall continually seek to improve on his/her professional skills, knowledge and expertise with other members of his/her profession and encourage their professional development.’20
Putting a code to work
Creating a code that remains on the shelf and is not made vital to an organization is a futile exercise. To become relevant, it must be integrated into the profession’s policies and processes. For example, processes for making decisions should be informed by a code of ethics (Resources for such ethical practices are on the Public Health Ethics and Law website.) Staff should receive in-house training in public health ethics, and curricula for public health degree programs can prominently feature ethics. A list of essential competencies can guide both individual and institutional behavior. For example, individual staff needs to be competently responsive, including listening well and by admitting mistakes or a lack of knowledge. Similarly, the institutions they work for need to establish processes and policies that enable and encourage responsiveness. Including an environment in which honesty and humility among the staff are encouraged, and where there exists an error culture of learning from mistakes.
Academic degree accrediting programs can require the inclusion of ethics in curricula (It is often debated whether ethics should be presented as stand-alone content or be integrated into each discipline. This is a false dichotomy: It is important to provide multiple modes of teaching.25) Institutions can include ethics in annual employee evaluations and after-action reviews, and provide resources for ethics-related processes, such as decision making.
The ethical practice of public health is not accidental. It stems from the intentional teaching of concerns to be sensitive to and skill in conducting processes that engender both trust and effectiveness. The successful development and implementation of these skills depends on institutions that deliberately create a culture, policies, and processes, that enable the ethical behavior of their staff. We have plans to collaborate with pilot sites to develop a community of learning in the use and generation of further learning, and additional assistance for competencies and other resources to support a code of ethics and competencies. Institutions attuned to ethics can provide a rewarding work environment for their staff, enabling them to thrive in part because they can be effective in ways that engender the trust and respect of the public.
James C. Thomas, Professor Emeritus
Peter Schröder-Bäck, Prof. Dr.
Katarzyna Czabanowska, Prof. Dr.
Paul Athanasopoulos, Dr.
Joseph Mfutso-Bengo, Professor
Carrie Baldwin-SoRelle, MSc, Librarian
Lena Strohmeier, MSc, Researcher
Farhang Tahzib, Dr FFPHM
Contributor Information
James C Thomas, Department of Epidemiology, University of North Carolina, Chapel Hill, NC 27599, USA.
Peter Schröder-Bäck, Institute for Ethics and History, University of Applied Sciences for Police and Public Administration in North Rhine-Westphalia, Aachen, Germany.
Katarzyna Czabanowska, Department of International Health, Care and Public Health Research Institute (CAPHRI) FHML, Maastricht University, Maastricht, The Netherlands; Department of Health Policy Management, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University, Krakow, 31-066, Poland.
Paul Athanasopoulos, Department of Public Health, NHS Forth Valley, Stirling, FK9 4SW, United Kingdom.
Joseph Mfutso-Bengo, Department of Health Systems and Policy, College of Medicine, University of Malawi, Blantyre, Malawi.
Carrie Baldwin-SoRelle, Health Sciences Library, University of North Carolina, Chapel Hill, NC 27599, USA.
Lena Strohmeier, Department of International Health, FHML, Maastricht University, Maastricht, The Netherlands.
Farhang Tahzib, Faculty of Public Health, London, NW1 4LB, United Kingdom; Global Network for Academic Public Health.
Funding
There were no funds supporting this project.
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