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PUBLIC HEALTH MATTERS
<br /> An Ethics Framework for Public Health
<br /> Nancy E . Kass , ScD
<br /> More than 100 years ago, public health began as an organized discipline , its purpose being to im- vital health statistics. Governments began
<br /> prove the health of populations rather than of individuals. Given its population- based focus, however, conducting investigations of housing condi-
<br /> tions and garbage heaps and mapping them
<br /> public health perennially faces dilemmas concerning the appropriate extent of its reach and whether in relation to outbreaks of disease,2 and by
<br /> its activities infringe on individual liberties in ethically troublesome ways. In this article a framework for the end of the 19th century, state and local
<br /> ethics analysis of public health programs is proposed . boards of health were being created to en-
<br /> To advance traditional public health goals while maximizing individual liberties and furthering so- force sanitary regulations. ' )N)iG0-61)
<br /> cial justice, public health interventions should reduce morbidity or mortality; data must substantiate By the early 20th century, public health
<br /> that a program (or the series of programs of which a program is a part) will reduce morbidity or mor- was seen as cost-effective as well as useful,2
<br /> tality; burdens of the program must be identified and minimized ; the program must be implemented and more money was directed to public
<br /> fairly and must, at times, minimize preexisting social injustices; and fair procedures must be used to health programs. During World War II, given
<br /> determine which burdens are acceptable to a community. (Am J Public Health. 2001 ;91 : 17764782) the need for a healthy population for the mili-
<br /> tary, the US Public Health Service established
<br /> the Center for Controlling Malaria in the War
<br /> Public health as an organized discipline began clnucal practice and research. A first attempt Areas, later the Centers for Disease Control
<br /> more than 100 years ago, with the goal of im- at such a framework is offered here. and Prevention. Epidemiology developed as
<br /> proving the health, primarily, of populations the science of public health, to study "the dis-
<br /> rather than of individuals. Given its popula- PUBLIC HEALTH t ibution and determinants of health-related
<br /> tion-based focus, however, public health con- states or events in defined populations and [to
<br /> titmally faces dilemras concerting the appro- Pubfic health is the societal approach to apply this knowledge] to the control of health
<br /> priate extent of its reach and at what point protecting and promoting health. Generally problems."3(p42)
<br /> the work of public health professionals is in- through social, rather than individual, actions, Today, public health practitioners use
<br /> fringing on individual liberties in ethically public health seeks to improve the well-being tools in addition to epidemiology to accom-
<br /> troublesome ways. Nonetheless, there have of communities. By maintaining a safe water plish their work, still focusing primarily on
<br /> been few attempts to articulate an ethics of supply, immunizing schoolchildren, or engag- communitywide, typically prospective, ap-
<br /> public health. ing in epidemiologic research, public health proaches to improve health. Some public.
<br /> Bioethics, as a discipline, helps health care seeks to ensure societal conditions under health functions—surveillance, vital statistics,
<br /> professionals identify and respond to moral which people can lead healthier lives, ' mini- disease and injury reporting, and disease
<br /> dilemmas in their work. In this article I sug- mining threats to our health "that can be registries—relate to epidemiology and the
<br /> gest that the contexts out of which bioethics averted or lessened only through collective collection of data. In addition, practitioners
<br /> emerged—medical care and human research— actions aimed at the community." ' (p20) The investigate outbreaks, conduct contact trac-
<br /> were oriented toward a different set of con- providers of public health interventions often ing, provide health education and other pre-
<br /> cerns than those typically arising in public are governments, rather than private practi- ventive interventions, and conduct research
<br /> health. While the founders of bioethics articu- tioners. Indeed, the provision of health sere- related to public health. Last, public health
<br /> lated principles equally relevant for public ices, generally the domain of medicine, be- professionals sometimes create or enforce
<br /> health, the more specific action guides and comes the responsibility of public health health-related regulations and legislation, for
<br /> codes of health care ethics that have followed departments when services are provided by example, mandating screening, treatment,
<br /> are an imperfect fit for public health. Codes public clinics or hospitals. immunizations, or—rarely—quarantine.
<br /> of medical and research ethics generally give Public health interventions date back more. States' authority to pass laws to improve the
<br /> high priority to individual autonomy, a prior- than 3 centuries. In 1701 , Massachusetts public's health dates to the 19th century and
<br /> ity that cannot be assumed to be appropriate passed laws for isolation of smallpox patients is referred to as the "police power" : "coercive
<br /> for public health practice. and quarantine of ships. rlP57) In the early action under state authority to encourage edu-
<br /> A framework of ethics analysis geared 1800s, Edward Chadwick demonstrated in cational efforts . . . seize property, close busi-
<br /> specifically for public health is needed, both England that differences in social conditions nesses, destroy annuals, or involuntarily treat
<br /> to provide practical guidance for public health led to a more than 2-fold difference in life ex- or even lock away individuals." (02) These
<br /> professionals and to highlight the defining val- pectancy between upper and lower classes. various public health tools and fractions,
<br /> ues of public health, values that differ in Also in the 1800s, Lemuel Shattuck, in Mass- while together successful in decreasing mor-
<br /> morally relevant ways from values that define achusettz, implemented the first system of bidity and mortality, nonetheless raise ques-
<br /> 1776 i Public Health Matters Peer Reviewed I Kass American Journal of Public Health I November 2001 , Vol 91, No. 11
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