Public Health Code of Ethics: Deliberative Decision-Making and Reflective Practice

In public health, ethical practice sustains the functioning of public health organizations and the integrity of individual public health practitioners. Ethical conduct promotes and preserves public trust, which is necessary to achieve public health goals. To facilitate ethical conduct among the public health workforce, the American Public Health Association (APHA) adopted a Public Health Code of Ethics effective November 2019, updating and replacing the code adopted in 2002.¹ The new code outlines values, standards, and obligations for public health organizations and individual personnel. It addresses the growing complexity of public health problems by using social justice and social determinants of health as framing tools for decision-making. It also outlines a decision-making framework to guide personnel through difficult choices that arise in practice.

In 2015, the APHA convened a task force of individuals from numerous APHA Member Sections to bring diverse perspectives in public health practice, research, education, policy, and science to prepare an updated Public Health Code of Ethics.² The task force used an iterative, deliberative, and consensus-building process and engaged national, state, local, territorial, and tribal public health practitioners and organizations, drawing on their perspectives and concerns to determine both the scope and the content of the new code. Broad input was received from APHA members (including the APHA Intersectional Council), other national public health organizations (e.g., Association of Schools and Programs of Public Health, Association of Public Health Laboratories, National Association of City and County Health Officials, Council of State and Territorial Epidemiologists), and members of the general public health community.

The new Public Health Code of Ethics delineates essential values that inform public health as it strives to promote human flourishing.² These core public health values are professionalism and trust; health and safety; health justice and equity; interdependence and solidarity; human rights and civil liberties; and inclusivity and engagement. These values reflect many ethical schools of thought, and the code shows how these multiple values can complement one another. The code also examines how deliberation and decision-making can proceed when these values conflict.³ As a practical tool, the code now provides guidance for ethical action and implementation of ethical strategies in key domains of public health practice. The code does not carry with it a mechanism for disciplinary sanction or enforcement. Its influence on professional conduct derives from values and standards widely shared in the public health profession and from the force of reasoned argument. It is sensitive to the varied nature of public health work and the variety of contexts in which it takes place. The code provides an ethical framework to guide both individuals and organizations as they pursue the health of the public.

IMPLEMENTATION OF THE CODE

In addition to attending to the ethical standards of the public health profession, public health practitioners must gain skills in decision-making when values conflict, as they often do in practice. Public health efforts such as isolation and quarantine to prevent the spread of serious infectious diseases, for example, can result in conflict between the obligation to promote population health and safety and the obligation to protect human rights and civil liberties.

The resolution of ethical conflicts does not always entail a single right path forward; rather, in ethically complex situations, it can mean identifying a range of morally appropriate decisions and actions in light of the full context of the problem—the factual evidence, the moral dimensions, and the lived experience of affected parties.⁴ Often, public health practitioners must respond in situations when complete or strong factual evidence is unavailable, which makes the ethical framework for decision-making even more salient. Skills in ethical analysis and reasoning represent an important competency for public health practitioners and leaders. They are an essential part of professional judgment and productive deliberation about public health action.³ To avoid arbitrary decisions or abuses of public trust, the new code recommends that public health practitioners reflect on the following key considerations through deliberative decision-making processes: permissibility, respect, reciprocity, effectiveness, responsible use of scarce resources, proportionality, accountability and transparency, and public participation (Table 1).³

TABLE 1—

American Public Health Association Public Health Code of Ethics, November 2019: Key Considerations for Ethical Analysis³

Consideration	Ask	Motivation
Permissibility	Would the action being considered be ethically wrong even if it were to have a good outcome?	Evaluating consequences of a proposed action or decision is always ethically pertinent but not ethically sufficient. To identify ethically suspect actions, considerations such as rights, duties, dignity, and equity also should be examined.
Respect	Would the proposed action be demeaning or disrespectful to individuals and communities even if it benefited their health?	Respect supports human dignity within transactions, exchanges, and relationships. To identify actions that are ethically suspect, the social and cultural context of the proposed action should be considered. These considerations remain relevant even when a significant disparity in need or resources exists among the parties involved.
Reciprocity	Have we done what is reasonable to offset the potential harms and losses that the proposed action imposes on individuals and communities?	Reciprocity asserts that social life should reflect mutual exchanges and cooperation. Reciprocity obligates us to relieve, as much as is reasonable, the burdens of adhering to public health policy. Even when the benefits and burdens of policy have been apportioned equitably, the fair share of some persons or groups still may cause hardship, and public health should try to ease it.
Effectiveness	Is it reasonable to expect, based on best-available evidence and experience, that the proposed action would achieve its stated health goals?	Given the best information available, a proposed public health action or decision should be able to achieve its intended public health goal. Action for its own sake without a reasonable likelihood of effective success is not ethically justified.
Responsible use of scarce resources	Would the proposed action result in good stewardship and deserve the trust that the public has invested in public health practitioners?	Even if permissible and effective on its own terms, ethical decision-making requires consideration of whether a given action merits expenditure of resources in relation to other needs or health goals that require attention.
Proportionality	Would the proposed action show that public health practitioners are using their power and authority judiciously and with humility?	Virtually every public health action has benefits and costs, particularly those for which difficult ethical judgments must be made. Proportionality involves assessments of the relative effects, positive and negative, of an action or a decision.
Accountability and transparency	Would the proposed action withstand close ethical scrutiny and be justified by valid reasons that the general public would understand?	Public health practice relies on the support and voluntary cooperation of individuals and communities, both of which require trust. Trust is built on ongoing transparency and accountability.
Public participation	In deciding on a proposed action, have all potentially affected stakeholders had a meaningful opportunity to participate?	Public participation refers to the meaningful involvement of members of the public in research, decision-making, planning, policy, and practice. Public participation should ensure that participants and decision-makers alike are mutually informed and engaged in dialogue and exchange.

To provide specific, concrete guidance, the code contains recommendations for ethical action in 12 domains of practice, using the framework developed by the Public Health Accreditation Board.⁵

FUTURE DIRECTIONS AND OPPORTUNITIES

The ethical conduct of public health practitioners is shaped by professional socialization, as well as systemic, institutional, cultural, and psychological factors. These factors must be met with strategic efforts to affect organizational culture and build professional capacity. The Public Health Code of Ethics has been written to facilitate continuing education and training activities and to advance the professional capacities of the public health workforce.

Ethics is a discipline that serves as a lens through which all public health practices should be viewed. Regardless of one’s role (e.g., teaching, research, or local health department program implementation) or practice context (e.g., public agency, university, or nongovernmental organization), practicing public health in an ethical manner is crucial.

Having a code of ethics to focus reflection, debate, and critical thinking is only the first step in the pursuit of ethical public health practice. The APHA Ethics Section, for example, intends to enhance the value of the code and support those who use it by integrating it into the Section’s own professional responsibilities, such as considering the values and guidance outlined in the code while reviewing proposed APHA policy statements. Ethics Section policy reviewers will look for discussion of relevant public health values and whether the ethical analysis reflects the best practices described in the code, including the use of the strongest available factual evidence, an explicit moral justification for the proposed policy, and an appreciation for the lived experience of stakeholders. The Ethics Section also will develop an online ethics resource library that will include a variety of tools, articles, and training materials that focus on public health ethics.

CONCLUSIONS

The promulgation of written codes of ethics alone is not sufficient to ensure professionalism in practice. Other obstacles to ethical public health practice—factors such as prejudice, bureaucratic inertia, and tunnel vision—must be addressed as well. Some scholars are skeptical about the role of codes in promoting ethical professional conduct. Nonetheless, it is important for professionals to communicate through codes of ethics the expectations they have for members of the profession. Developing or revising codes of ethics can motivate a healthy process of institutional self-reflection and sensitization. Once established, codes of ethics can play a meaningful part in promoting and sustaining a humane and respectful ethos of moral recognition and care in public health.⁶ Codes of ethics are not manuals or checklists to be followed mechanically, but their language and provisions can be a touchstone for ethical reflection and deliberation. By providing critical diagnoses and aspirational alternatives, codes of ethics can even begin to address the structural and cultural factors that make the conduct of the field fall short of its own ideals and those of the broader society.

A public health code of ethics must reflect the field’s unique moral obligation to ensure the health of populations—as well as individuals—through practices and policies that foster the fair distribution of basic resources and conditions necessary for health, protection of individual and collective rights, and respect for the ecologies in which we live. This code, like all effective codes of ethics, “embodies the collective conscience of a profession and is testimony to the group’s recognition of its moral dimension.”⁷