|
PUBLIC HEALTH MATTERS
<br /> tions of ethics in terms of the means by which viously, was now given preeminent moral We live in a morally pluralistic society, and
<br /> these successes are achieved. status.8-10 Informed consent, a practical ap- it is inevitable that moral appeals will conflict
<br /> plication of the autonomy principle, became when attempts are made to determine appro-
<br /> BIOETHICS AND PUBLIC HEALTH a hallmark of the new bioethics, and codes priate public, policy. A framework for public
<br /> of ethics for clinical practice, while still em- health ethics will help public health profes-
<br /> Bioethics helps health professionals and phasizing the need not to harm the patient, sionals recognize the multiple and varied
<br /> public policymakers recognize moral dilem- added clauses requiring physicians to "best moral issues in their work and consider
<br /> mas in health care and biomedical research care for the dignity of man in patients or re- means of responding to them.
<br /> and provides principles and moral rules with search subjects." u(par)
<br /> which to navigate through these dilemmas. (A That contemporary medical ethics or re- AN ETHICS FRAMEWORK FOR
<br /> framework of bioethics based on principles, search codes have made the right to noninter- PUBLIC HEALTH
<br /> as put forward by Beauchamp and Childress,5 ference central is understandable, given the
<br /> will be used here. However, there are many context out of which they emerged. That pub- A 6-step Framework is proposed for consid-
<br /> other bioethical frameworks, including, for ex- lie health practitioners, lacking guidelines of eration. Components of this framework were
<br /> ample, ethics of care, casuistry, and virtue- their own, must turn to these same codes for proposed in an earlier article,15 and a similar
<br /> based ethics.) professional moral direction, however, is framework was proposed for public health
<br /> Dating to the 1960s and 1970s, bioethics more problematic In rare instances, existing and human rights by Gostin and Lazzarirri. ls
<br /> grew out of questions of fairness in resource medical or research codes do discuss tradi- This is not a code of professional ethics,
<br /> allocation, moral issues raised by new tech- tional public health functions, such as breach- which more likely would address general
<br /> nologies, and a lack of oversight in human- ing patient confidentiality to report diseases norms and expectations of professional be-
<br /> subjects research. The public was swept up to the state. 12 In such instances, however, the havior and probably would be the product of
<br /> in debate about whether the first artificial physician's behavior is presented as an allow- a professional society. Rather, this is an ana-
<br /> kidney center should allocate scarce re- able exception to usual ethics rules in the lytic tool, designed to help public health prom
<br /> sources on the basis of social criteria and name of public health. fessionals consider the ethics implications of
<br /> whether Karen Ann Quinlan should be kept At best, this leaves public health profes- proposed interventions, policy proposals, rem
<br /> alive artificially when she had no meaningful sionals needing to muddle through most search initiatives, and programs.
<br /> cognition. other situations on their own; at worst, it
<br /> In 1969, the Institute of Society, Ethics, could lead them, or even the public, to as- 1. What are the public health goals of
<br /> and the Life Sciences (now the Hastings Cen- sume that public health is the branch of the proposed program?
<br /> ter) was created to address questions of health care sanctioned by bioethics to make The first step for any proposed public
<br /> bioethics and to provide frameworks with exceptions to existing ethics rules at will, in health program is to identify the program's
<br /> which to analyze contemporary moral dilem- the name of public health and safety. In= goals. These goals generally ought to be ex-
<br /> mas in medicine and science,6 In 1974, after deed, it is in great part because such power pressed in terms of public health improve-
<br /> several reports of US government sponsored is vested in public health by law that a code ment, that is, in terms of reduction of mor-
<br /> research that compromised the rights and or framework of ethics designed specifically bidity or mortality. For example, an HIV
<br /> welfare of study subjects, a new national comm for public health is so very important. The screening program should have as its ulti-
<br /> mission issued the Belmont Report, which in- need for a code of ethics for public health, mate goal fewer incident cases of HIV, not
<br /> eluded ethics principles to guide the conduct then, might be viewed as a code of re- simply that a certain proportion of individu-
<br /> of human subjects research—beneficence, re- straint, a code to preserve fairly and appro- als will agree to be tested. A health education
<br /> spect for persons, and justice,7 Eally flamers priately the negative rights of citizens to program in cardiac risk reduction should
<br /> of bioethics elaborated on these principles noninterference, have as its ultimate goal (or the ultimate goal
<br /> and provided examples of how they were use= A code or framework of public health of a larger program of which it is a part) that
<br /> ful in analyzing dilemmas from other areas of ethics must emphasize positive rights as well, individuals will have fewer heart attacks, not
<br /> health care, not just research,5 however. Public health has affirmative obli- simply that individuals will learn new inform
<br /> These early framers argued that, a priori, gations to improve the public's health and, mation or even that they will change their
<br /> no principle ought to have moral superiority arguably, to reduce certain social inequities. behavior. A research study should have as its
<br /> over any other. At the same time, the issues A code of public health ethics is needed to ultimate goal (or the ultimate goal of a larger
<br /> that animated bioethics in the early years— address such social justice functions of pub= trajectory of which it is a part) that findings,
<br /> the need to tell patients and research sub- lie health. While frameworks have been put if positive, will be implemented with the tar-
<br /> jects the truth, the patient's right to refuse forward in medicine to help clinicians think get population and improve its health status.
<br /> care or research participation—were ones in through the ethical issues in a clinical While more proximate and process goals
<br /> which the principle of respect for autonomy, case, 1114 no analogous framework is avail- (such as whether individuals will learn
<br /> perhaps given too little moral attention pre- able for public health practitioners. health information or whether they will
<br /> American Journal of Public Health November 2001 , Vol 91 , No . 11 Kass Peer Reviewed Public Health Matters 1777
<br />
|