Figure 1.
Journal readers will not need to be reminded of the responsibility of public health practitioners and scientists to conduct their practices ethically. Nor need they be alarmed that ethical review of their practices might disclose histories of ethical misconduct. Both routine and exceptional initiatives in public health are usually undertaken ethically.
Public health practice may nevertheless be enriched by perceptions of how practice can be explicitly responsive to ethical concerns, and how the choice of options in the design and implementation of projects can be enhanced by a sense of ethical values. Ethical insight into projects may afford opportunities for initiatives that add to the projects’ value and the satisfaction of those involved.
Ethics is not best applied as a directive superstructure. Ethics related to issues of biology, often called bioethics, has attracted justified criticism when its practitioners—bioethicists—condescendingly pronounce on the ethics of practice or admonish those conscientiously undertaking advancement of health interests for offending refined ethical principles. Ethics is better applied collaboratively, equipping practitioners to maximize the ethical advantages and minimize the ethical costs of their proposals.
Modern principles of bioethics, which have their roots in ancient moral philosophy, have been popularly distilled in the 1978 Belmont Report of the National Commission for Protection of Human Subjects of Biomedical and Behavioral Research. These widely respected core principles offer guiding values for both research and epidemiological practice. The first principle, that persons be treated with respect, requires that autonomy be accorded a high value and that persons incapable of self-determination be protected against exploitation and abuse.
Second is the duty to maximize good, or beneficence. This extends beyond the third principle, nonmaleficence, the historic medical ethic to do no harm, in requiring positive acts of good when harm is avoidable simply by inaction. Fourth is the ethical principle of justice, particularly distributive justice directed to the just allocation of risks and benefits.
The challenge to public health practitioners, accepted by the American Public Health Association (http://www.apha.org/codeofethics/ethics.htm), is to apply these principles not just individually but at the collective (macroethical) level. The 4 Belmont principles have equal rank. Since one may be applied to subordinate others, practitioners must justify their ordering of priorities. For instance, a study in which each informed individual freely consents to participate respects the individuals’ autonomy but may be considered harmful by the communities to which they belong. Similarly, a study approved by the public to advance a community’s well-being may be opposed by individual members whose privacy or self-interest is compromised. Issues of consent, confidentiality, benefit, and risk perception may have to be resolved at a community or democratic level even though individuals’ personal interests warrant appropriate protection.
There are often different ethical approaches to implementing projects. Those favoring particular prioritizations of values may regard other approaches not as unethical, but as affording different weight to ethical principles and values. The role of ethical analysis is to require proponents to articulate the principles or values at stake and to justify why they have elevated or subordinated each of them. When ethical analysis does not produce agreement, it can facilitate respectful disagreement and open understanding of ethical options.