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PUBLIC HEALTH MATTERS
<br /> by a program—for example, in terms of cost, about ethnic groups or neighborhoods that not able to decide for themselves whether to
<br /> constraints on liberty, or targeting particular, may be stigmatizing or otherwise harmful. release their names to officials. As stated
<br /> already vulnerable segments of the popula- Communicable disease reporting raises prim above, banns can occur if confidentiality pro=
<br /> tion—the stronger the evidence must be to vacy concerns as well, but the infringement tections fail, and individuals can feel wronged
<br /> demonstrate that the program will achieve its and risks potentially are greater, since names simply by virtue of the violation of their prim
<br /> goals. Indeed, because many public health are reported only of those who have re- vacy. Justice concerns also arise if contact
<br /> programs are imposed on people by govern- portable (and often socially stigmatizing) tracing programs are not implemented fairly.
<br /> ments and not sought out by citizens, the bur- conditions. Given that individuals typically Health education poses interesting questions
<br /> den of proof lies with governments or public want the ability to control whether and to in terms of ethics. In certain ways, health edu-
<br /> health practitioners to prove that the program whom private information is disclosed, dis- cation is the ideal public health intervention,
<br /> Will achieve, its goals. Thus, if at least some ease reporting carries the additional risk of a since it is completely voluntary and seeks to
<br /> data do not exist that demonstrate the validity breach of confidentiality if security measures empower people to make their own decisions
<br /> of a program's assumptions, the analysis can are not followed or do not work. For some, regarding their health once they are equipped
<br /> stop right here, and, ethically, the program there is a risk of privacy infringement only with accurate information. From an ethics
<br /> should not be implemented. Conversely, the to the extent that confidentiality is not main- perspective, education clearly is preferable to
<br /> presence of good data alone does not justify tained and harms such as social stigma or other preventive strategies, to the extent that
<br /> the program; it allows us to move to the next loss of employment ensue from unwarranted they are equally effective, because it poses
<br /> stage of the analysis. disclosure. For others, the privacy infringe- few, if any, burdens.
<br /> ment is viewed as a wrong in itself, regard- Health education, however, although an es-
<br /> 3. What are the known or potential less of whether any tangible harm ensues. sential component of most public health cam=
<br /> burdens of the program? Disease reporting is an example of a public paigns, will not be appropriate for all situa-
<br /> If data suggest that a program is reasonably health function that, at least on its face, is dis- lions. Fast, education may not work in all
<br /> likely to achieve its stated goals, then the tributionally unfair, in that the burdens of the settings, and more burdensome measures
<br /> third step of the framework asks us to identify program are borne by those with the disease, may be required. Second, to increase effeem
<br /> burdens or harms that could occur through generally for the benefit of others who do not tiveness, educational programs may introduce
<br /> our public health work. have the disease. This unevenness of burdens ethically questionable practices, such as ma-
<br /> Although a variety of burdens or harms and benefits may be justified in certain in- nipulation or even coercion. A smoking cessa-
<br /> might exist in public health programs, the ma- stances, when the benefits are important and tion program, for example, may try to manip-
<br /> jority will fall into 3 broad categories: risks to when there are no less burdensome ways to ulate attitudes by suggesting that smokers are
<br /> privacy and confidentiality, especially in data achieve them. Unevenness in benefits and unpopular and by providing only partial or
<br /> collection activities; risks to liberty and self- burdens is never appropriate, however, if even false information to achieve its ends.20
<br /> determination, given the power accorded groups are burdened in ways that are arbi- Third, all health education campaigns are
<br /> public health to enact almost any measure tary and without public health justification. potentially paternalistic, suggesting that cer-
<br /> necessary to contain disease; and risks to jus- Further, a program that does not target parties tain ways of being (e.g., in greater aerobic
<br /> lice, if public health practitioners propose tar- War groups explicitly may, in fact, lead to tar- health) are universally valued. Additional
<br /> geting public health interventions only to cer- geting in its implementation. One study, for work is needed to examine when and where
<br /> tain groups. Different types of burdens are example, suggested that doctors are more paternalism in public health is justified, es-
<br /> more or less likely to result from different likely to report a patient with HIV to the pecially since biomedical ethics generally
<br /> types of public health activities, health department if the patient is Black and has steered professionals away from pater-
<br /> Disease surveillance and vital statistics, de- male,'a despite language in the statute requir- nalism except when it is specifically re-
<br /> signed to monitor health and population ing the reporting of all persons with HIV. The quested by patients. (See Bernard Lo for a
<br /> trends, raise potential privacy concerns, espe- appropriateness of creating targeted public discussion of paternalism in which he con-
<br /> cially since data collection is mandatory and health programs justified by epidemiologic eludes that "when disagreements persist
<br /> data often are individually identifiable and, in data is discussed further in step 6. after repeated discussions, the patient's in-
<br /> many cases, publicly available. Although the Contact tracing, which sometimes accompa- formed choices and definition of best inter=
<br /> types of data collected are not considered nies communicable disease reporting, poses ests should prevail,"2rtpN39-431 and a discus=
<br /> very personal or sensitive by most persons, additional privacy risks. Not only are an indi- sion of patients who do not want to make
<br /> everyone has his or her own boundary of prim vidual's name and condition reported, but in- their own decisions.2r [P29])
<br /> vacy. Further, for some individuals, particular dividuals are asked to provide the names of Fourth, health education programs may tar-
<br /> elements of vital statistics, such as paternity or other (usually sexual) contacts they have had, get messages to certain audiences. Although
<br /> cause of death, could be seen as invasions of Obviously a privacy infringement in itself, such targeting is often justified on public
<br /> their privacy. Finally, vital statistics and other contact tracing also invades the privacy of in- health grounds (e.g., epidemiologic data dem-
<br /> publicly collected data can reveal patterns dividuals whose names are disclosed, who are onstrate that members of this population are
<br /> American Journal of Public Health I November 2001 , Vol 91, No. 11 Kass I Peer Reviewed I Public Health Matters 1 1779
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