Public Health and Bioethics: The Benefits of Collaboration

Public health professionals operate under the moral imperative to ensure and protect the public's health. The ethical foundations of public health practice have always been implicitly assumed, by both members of the profession and the public at large. However, until recently, the basic values that underlie public health decisions and the conflicts inherent in its practice have rarely been articulated.1 During the past 2 decades, the AIDS epidemic has caused the field to be more aware of the values at stake when individual rights and the public good come in conflict.2,3 Exploring these complex questions and discovering that there are other important value conflicts in public health have caused academic leaders and practitioners alike to call for more attention to the fundamental ethical underpinnings of the field.

The Public Health Leadership Society has brought together professionals from local and state public health departments, schools of public health, the Centers for Disease Control and Prevention, and the American Public Health Association (APHA) to develop a Public Health Code of Ethics. In November 2001, they presented a draft code at a “town meeting” at the APHA annual meeting. It is anticipated that a number of public health organizations will adopt the code.1 There are also efforts to develop more courses and curricular materials to educate students about public health ethics.4 While there have been some good preliminary works published,5–7 many important issues in public health ethics have not yet received the attention they require, and there is as yet no comprehensive body of work to provide the foundation necessary for the field.

THE ROLE OF BIOETHICS IN PUBLIC HEALTH

This issue of the Journal features a commentary by Daniel Callahan and Bruce Jennings, writing for the members of the Hastings Center Project on Ethics and Public Health.8 The Hastings Center was the first bioethics think tank, and it remains one of the leading institutions in the world devoted to the examination of bioethical issues.

Callahan and Jennings review some of the history and orientations of the 2 fields of bioethics and public health, and discuss some of the potential that each has to contribute to the other—the potential of bioethics to bring expertise in defining and illuminating ethical problems to the domain of public health, and the potential of public health to broaden the concerns of bioethics. They also discuss some of the challenges of this collaboration. In particular, they point out the dominant focus on the welfare and rights of the individual in bioethics, in contrast to the focus on the health of populations and societal concerns in public health. Moreover, they highlight “the tension produced by the predominant orientation in favor of civil liberties and individual autonomy that one finds in bioethics, as opposed to the utilitarian, paternalistic, and communitarian orientations that have marked the field of public health throughout its history.”8⁽¹⁶⁹⁾

Callahan and Jennings discuss their view of the scope of public health ethics, the types of ethical analysis that may provide assistance in sorting out the ethical concerns of public health, some particular issues in public health that they believe deserve attention, and the importance of creating opportunities for education in public health ethics for public health students and practitioners. The commentary ends with a series of recommendations to foster the discussion and advancement of ethics in public health and attention to issues of public health within the field of ethics.

Public health professionals should applaud the work and insights of Callahan, Jennings, and the Hastings Center group and recognize that the field of bioethics can be an important contributor to the future growth and development of public health. Public health can also greatly benefit the field of bioethics by broadening the primary focus of bioethics from individual autonomy and clinical care to include the contextual issues in health care decision making, the value conflicts inherent in population-based programs, and the social and structural determinants of population health.

THE SCOPE OF PUBLIC HEALTH ETHICS

In their article, Callahan and Jennings narrowly define the scope of public health ethics and focus on a limited set of problems associated with health promotion and disease prevention, risk reduction, public health research, and disparities in health status. As the field of public health ethics develops, it will need to consider broader sets of dilemmas that are fundamental to public health. For example, there are many questions concerning the allocation of resources. Such questions arise in a number of domains. First, at the highest level, there are questions that go to the heart of political debates about the appropriate distribution of societal resources. To what extent should resources be devoted to health as opposed to other human goals? Second, there are questions about the relative distribution of resources between health care delivery and public health endeavors. Third, for public health professionals, there are significant value conflicts about the degree to which efforts should focus on ensuring equitable access to health care, reducing the risk of disease, or addressing fundamental determinants of health. Fourth, from among the many health problems that exist, public health professionals must decide which issues to address and the relative amount of financial and human resources to devote to each.

Discussions of ethical issues in public health are often presented primarily as conflicts between the rights of identified individuals and the responsibilities of the state to protect their health or the well-being of others. However, ethical issues in the practice of public health also often arise because of differences in the beliefs and values among members of groups, between the interests of different populations, or between populations and institutions. The expertise of bioethics in addressing value conflicts, including some of the types of ethical analyses described by Callahan and Jennings, will be useful for the understanding of many of these dilemmas.

The involvement of communities in strong collaborative partnerships is an important goal for public health practice. Yet questions often arise concerning which people make up the relevant members of a community and which people can be said to represent its interests. Ethical analyses could be useful for deciding how to incorporate the participation of community members and identifying the community's interests and needs.

THE UTILITY OF ETHICAL ANALYSIS

Ethical analysis can further understanding in every area of public health practice. For example, for practitioners working on issues of substance abuse, ethical analysis could help elucidate questions such as the following: How should one deal with the differing concerns of substance users, family members, and other community residents? What role should different community members play in determining whether a needle exchange program or substance use treatment facility will be built in a neighborhood? Who should participate in decisions about the allocation of resources to address the problems of injecting drug users as opposed to programs to prevent the initiation of injecting drug use or to prevent the use of tobacco? Ethical analysis could also be useful to public health researchers and advocates as they examine larger societal issues such as the benefits and burdens of tougher drug enforcement policies or of changes in the tax code that would affect patterns of income disparity.

Ethical analysis could also illuminate value considerations inherent in responding to recently emerging public health challenges such as the outbreak of the West Nile virus. The media portrayed the disease as a potentially fatal illness that, because of its spread by mosquitoes, could affect anyone. The departments of health in New York City and the surrounding region had to quickly decide how to immediately respond to the new public threat as well as develop a long-range plan; at the same time, they also had to continue to address other public health problems with their limited resources. While decisions about the development of a public health program are often conceptualized as based on scientific evidence and administrative exigencies, implicitly or explicitly, they also involve political considerations and value judgments. The development of the response to West Nile involved judgments about the seriousness of the condition, the meaning of the level of risk, the significance of the harm to populations at risk, the appropriateness of various types of interventions, the relative costs of alternative actions and interventions, and the relevance of public concerns, as well as consideration of competing public health needs. Ethical analysis provides the means for elucidating such value considerations and systematically examining the basis for decisions.

In the coming months, public health professionals at all levels of the government are likely to face even more difficult decisions as additional resources are allocated to enhance the public health infrastructure in response to concerns about terrorism and public safety. Ethical analysis would be useful as health departments work to balance these appropriate concerns with the other essential public health obligations.

THE BENEFITS OF COLLABORATION

Although skeptical at first, most medical professionals now view their collaboration with bioethicists over the last 30 years, on such issues as health care decision making, the allocation of scarce resources, and human subjects research, as constructive and helpful. Sustained conversations between bioethicists and public health professionals have the potential for similar positive outcomes. Initially, there should be the identification of critical issues. Bioethicists and public health professionals together will need to develop a vocabulary and appropriate methods of analysis for public health problems. The Journal is an excellent place to share the efforts of such an exploration. Ultimately, we believe that the fields of public health and bioethics will develop a shared understanding of each other's concerns that will enable them to better address ethical issues in public health.