For those of us who practice, administer, research, study, or teach public health, two aspects of the field inspire and motivate us—the importance of public health measures to the well-being of society and the constantly evolving nature of public health issues. Besides traditional public health concerns such as sanitation, environmental health, and infectious diseases, contemporary public health also focuses on—among other things—newly emerging pathogens, bioterrorism, and disaster response.
Although public health challenges have varied over time, the central ethical concern in public health has remained the conflict between individual and group interests in controlling disease and promoting health. The defining feature of public health is the legal authority of public health officials to impose coercive measures on individuals and entities for the benefit of society. Therefore, the basic ethical and legal question for public health is whether it is justifiable to restrain individual liberty by prohibiting travel, accessing personal health records, mandating medical examinations or treatment, prohibiting public gatherings, seizing or destroying property, closing businesses, or otherwise superseding individual interests to protect the public's health.
Public health policy requires a delicate weighing of scientific, legal, and political considerations—all influenced by public health ethics. To make matters even more challenging, the societal values affecting public health ethics are dynamic. The balance point between utilitarian and libertarian visions of a well-ordered society shift over time and vary among communities and societies.
It is impossible to predict all of the ways in which public health ethics challenges may arise in the future. Three areas are likely to be important: (1) public health genetics, (2) public health access to personal health information, and (3) public health and lifestyle.
Because its initial application was the appalling eugenics movement of the first half of the 20th century, public health genetics has been viewed with suspicion ever since. The great success of public health genetics is newborn screening, which began in the early 1960s. New tests now enable the screening of newborns for an ever-expanding panel of rare disorders, but at what opportunity cost, with what percentage of false-positives, with what follow-up, and with what level of parental anxiety? Another emerging issue is whether it is appropriate to use full genome sequencing as a public health tool for population screening.
New health information technology is changing the practice of medicine. Interoperable, comprehensive, and longitudinal electronic health records and networks promise more effective and efficient care, as well as enable outcomes research and public health data mining. A crucial challenge will be to balance individual privacy interests with potential public health benefits from medical surveillance. Without strong privacy protections individuals with stigmatizing conditions, such as mental illness, substance abuse, and sexually transmitted infections, may forego timely medical care and thereby endanger the public.
In the developed world, the bounties of prosperity are contributing to obesity, diabetes, hypertension, hypercholesterolemia, and other disorders. The abuse of alcohol, tobacco, and illicit substances also contributes significantly to excess morbidity and mortality. Beyond public education and health promotion, is it ethically and legally acceptable to adopt more coercive measures such as banning certain products or ingredients? Is the public benefit rationale that justifies coercive measures in the face of infectious disease applicable when the direct health consequences of lifestyle risks affect only the individual?
As long as society needs public health, it will also need public health ethics to identify the interests at stake, weigh alternatives, consider consequences, and help ensure that the benefits and burdens of public health interventions are distributed equitably across society.