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PUBLIC HEALTH MATTERS
<br /> at greatest risk, so their pictures will go on the Regulations and legislation, strictly speaking, tact tracing programs, strictly speaking, are
<br /> billboards and messages will be promoted on are coercive, since they impose penalties for voluntary, in that no sanctions are imposed
<br /> the radio stations they listen to), the social noncompliance. As such, they pose risks to lib- on citizens who refuse to cooperate. It is ethi-
<br /> and even public health ramifications of target erty and selPgovernance. While many of these tally incumbent on public health practitioners
<br /> ing must be seriously considered. Social measures, such as reduced speed limits, child- to inform individuals sought for contact trac-
<br /> stigma can result if, for example, certain sub- proof bottles, and immunization, have demon- ing of their right to refuse to disclose the
<br /> groups of the population are assumed to be strated efficacy, they nonetheless are the most names of their partners, as well as of their
<br /> the ones who carry sexually transmitted dis- intrusive approach to public health. Edmund right to inform partners themselves, have a
<br /> eases, and opportunities for public health in- Pellegrino and David C. Thomasma write: known health care provider do it, or have
<br /> tervention will be missed entirely if we all Involuntary and coercive measures must be partners contacted by an agent of the state.
<br /> come to believe, through well-intentioned undertaken with a clear perception of the dan- If 2 options exist to address a public health
<br /> media campaigns, that only certain groups are gers they pose to a democratic society: loss of problem, we are required, ethically, to choose
<br /> personal freedom to choose a lifestyle, depen-
<br /> at risk for domestic violence or HIV dense upon governments to define values and the approach that poses fewer risks to other
<br /> Finally, health education campaigns may concepts of the good life, and the imposition of moral claims, such as liberty, privacy, oppor-
<br /> be accompanied by incentives. Incentives gen- cultural homogeneity. Involuntary measures tunity, and justice, assuming benefits are not
<br /> also assume a benign, wise, and responsive
<br /> erally are considered ethically less problem goverrmrent—something history finds singularly significantly reduced. Making this assessment
<br /> atic than coercive measures or threats, but rare.10(d375) relies on the existence of sound data If data
<br /> even incentives could be ethically question- show that a voluntary screening program will
<br /> While threats to autonomy are the most
<br /> able in certain contexts, such as when finan- test essentially the same number of individu-
<br /> cial incentives are given for using particular obvious threats posed by public health r als as a mandatory one, because almost no
<br /> zz lotions and legislation, such regulations andd
<br /> types of birth control or avoiding pregnancy, one refuses testing when asked, then it would
<br /> legislation can, in some circumstances, be as-
<br /> Public health research carries burdens. Hu- sociated with physical risks, or risks to in be ethically improper to implement a manda-
<br /> di- z3tara 51
<br /> man subjects regulations already describe the viduals' health, as well. Federally approved tory program. v If disease surveillance is
<br /> types of harms that could occur through re equally effective with unique identifiers or
<br /> and mandated vaccinations carry health risks
<br /> search participation. These include medical with names, a program of unique identifiers is
<br /> risks if the research is clinical, and psycholog- to individuals widespread spraying pre- the morally preferable choice.
<br /> ical or social risks if the research is epidemio- vent the spread of mosgidto-borne viruses
<br /> can cause proximate health problems to
<br /> logic or social science. In recent years there some individuals who inhale the chemicals. 5. Is the program implemented fairly?
<br /> has also been increased attention to the per- This piece of the fiamework corresponds to
<br /> Finally, in this instance as well, the law can
<br /> sonal and social burdens that can result from & the ethics principle of distributive justice, re-
<br /> injustice or exploitation in research when impose, by design or inadvertently, threats to quirnig the fair distribution of benefits and
<br /> justice if regulations impose undue burdens 5(e fair
<br /> certain populations are disproportionately burdens. Public health benefits,
<br /> on particular segments of society.
<br /> disadvantaged or privileged through research such as clean water, cannot be limited to one
<br /> participation. 4. Can burdens be minimized? Are there community, nor can a single population be
<br /> In addition to these well-articulated risks, alternative approaches? subjected to disproportionate burdens. HIV
<br /> however, is the harm that can occur if public This piece of the fiamework requires us to screening programs, for example, cannot be
<br /> health research findings are never imple- minimize burdens once they have been identi- implemented only in poor or minority com-
<br /> mented in public health policy or practice. fled. If step 3 suggests that a program or policy munities without strong justification (see Stoto
<br /> Any study conducted imposes, at the very carries potential or actual burdens, we are ethi- et a1.23 for a discussion of why universal HIV
<br /> least, the burden of inconvenience on those tally required to determine whether the pro- screening programs are ethically preferable to
<br /> who participate, and may, of course, pose gram could be modified in ways that minimize targeted programs); cardiac risk reduction
<br /> more significant risks to the individuals or the burdens while not greatly reducing the programs cannot be targeted exclusively to
<br /> communities who volunteer. An institutional programs efficacy. Public health professionals, White men when women and minorities are
<br /> review board allows research to go forward for example, when ready to report a patients also at substantial risk of heart disease.
<br /> because of the benefits expected to emerge name and disease to the state, should inform That programs be implemented fairly is
<br /> from study findings. If research findings are patients that their names, by law, must be re- even more important if restrictive measures
<br /> never translated into policy, however—a situa- ported to public health authorities but that the are proposed. Injustice is wrong for its own
<br /> tion that occurs far too often—no benefits ac- law also requires that they be reported confi- sake, and also for the material harms it can
<br /> true from the research. In such instances, par- dentially. Although reporting programs are not evoke. Social harms result if social stereo-
<br /> ticipants were wronged through a misleading optional, the policy is more respectful of pa- types are created or perpetuated, such as the
<br /> (albeit not deliberately so) informed consent tients if patients are adequately informed. stereotype that only certain segments of the
<br /> process, and the risk-to-benefit ratio could Contact tracing programs, similarly, pose population are vulnerable to sexually trans-
<br /> rarely be considered favorable. threats to privacy and confidentiality. Yet con- mitted diseases. In addition, real public health
<br /> 1780 j Public Health Matters I Peer Reviewed Kass American Journal of Public Health I November 2001 , Vol 91 , No . 11
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