|
PUBLIC HEALTH MATTERS
<br /> harms result when individuals do not believe outcomes. Indeed, it is hard to find a more cedures. Procedural justice requires a society
<br /> that they are at risk for disease because they powerful predictor of health than class,2sas to engage in a democratic process to deter-
<br /> were never targeted in education campaigns, and it is thus an appropriate, if not obligatory, mine which public health functions it wants
<br /> or because their own doctors never screened function of public health to reduce poverty, its government to maintain, recognizing that
<br /> them for a condition because they didn't fit substandard housing conditions, and threats some infringements of liberty and other bur-
<br /> the popular risk profile.24 This does not mean to a meaningful education—if for no other rea- dens are unavoidable. There should be open
<br /> that programs or resources must be allocated son than to reduce the incidence of disease. discussion of what a society gains from good
<br /> equally to all communities—rather, the alloca- public health and why such benefits often
<br /> tions must be fair. That is, differences cannot 6. How can the benefits and burdens of cannot be obtained through less communal or
<br /> be proposed arbitrarily or on the basis of his- a program be fairly balanced? more liberty-preserving methods. The discus-
<br /> torical assumptions about who might be at If it is determined that a proposed public Sion, of course, should also address why other
<br /> risk. Again, unequal distributions of programs health intervention, policy, or program is interests also have moral claim. Such a pro-
<br /> must be justified with data. Moreover, the so- likely to achieve its stated goals, if its poten- cess, even when procedurally fair by most
<br /> cial consequences must be considered if a tial burdens are recognized and minimized, standards, must not result in decisions based
<br /> community is allotted resources unequally, and if the program is expected to be imple- solely on the will of the majority. Indeed dew
<br /> and these consequences must be balanced mented in a nondiscriminatory way, a deci- liberations, particularly around significantly
<br /> against the benefits to that community or sion must be reached about whether the ex burdensome proposals, must be scrutinized to
<br /> others. petted benefits justify the identified burdens. ensure that the views of the minority are
<br /> Discussed less frequently is whether, or the Recognizing, of course, that public policy is given due consideration. Highly burdensome
<br /> degree to which, public health has any ex- based on multiple considerations in addition programs should be preceded by public hear-
<br /> pli©t role in righting existing injustices, espe- to ethics, the question must still be asked ings, not just votes, so that minority views can
<br /> cially given the strong link between poor liw whether, from an ethics perspective, the pro- be heard and considered.
<br /> ing conditions and poor health outcomes. To gram should go forward. Health department At the same time, it is important to aew
<br /> what extent is there a positive responsibility officials and other public health professionals knowledge that there will always be some
<br /> on the part of public health professionals to may not have the power to implement all pro- number of persons who do not want their
<br /> advocate better housing, better jobs, and bet grams they think would be beneficial, but water fluoridated, do not want their children
<br /> ter access to food programs, since such advo- they do have a responsibility both to advo- immunized, do not want to wear seat belts,
<br /> cacy might be the best route to improving the cate programs that do improve health and to and do not want speed limits on public roads.
<br /> public's health? remove from policy debate programs that are That there is dissent is insufficient justification
<br /> Several notions of justice allow and even unethical, whether because of insufficient for blocking a public health program; indeed,
<br /> require unequal allocation of benefits to right data, clearly discriminatory procedures, or now dissent is inevitable in all proposals. Dissent
<br /> existing inequities. John Rawls posits that jus- justified limitations on personal liberties. must be considered, however, and it deserves
<br /> lice requires us to allocate our resources un- And yet while most reasonable people will special attention if it is raised exclusively by a
<br /> equally to help the least well-off.25 Norman agree, in the abstract, that burdens and bene- particular identified subgroup such as an eth-
<br /> Daniels discusses the need for all members of fits must be balanced, and that the most bur- nic minority, a particular age group, or resi-
<br /> society to be brought to a level of "species- densome programs should be implemented dents of a particular neighborhood,
<br /> typical normal functioning'Q15 which also only in the context of extensive and impor- In balancing values arid interests, the greater
<br /> could result in the unequal distribution of cer- tart benefits, disagreements are all but guar- the burden imposed by a program, the greater
<br /> tain resources. Admittedly, not all philoso- anteed over the details. Depending on one's must be the expected public health benefit,
<br /> pliers have adopted this notion of justice; perspective, there will be differing views over and the more uneven the benefits and burdens
<br /> some make a distinction between preexisting how burdensome various programs are, such (that is, burdens are imposed on one group to
<br /> societal inequities that are unfair (because as having one's name reported to the state or protect the health of another), the greater must
<br /> they resulted from a person or community being required to immunize children before be the expected benefit Programs that are cow
<br /> having been wronged by an identifiable they start school. Citizens can be expected to ercive should be kept to a minimum, should
<br /> source), where intervention is owed, and in- differ over how important it is to protect a never be implemented when a less restrictive
<br /> equities that are merely unfortunate (that is, water supply for future generations, particu- program would achieve comparable goals, and
<br /> due to acts of God or circumstance), where larly if it means significantly higher taxes or should be implemented only in the face of
<br /> no intervention is morally required.27 prohibiting recreational use of a public body clear public health need and good data dew
<br /> Public health, I would argue, does have a of water—which is clearly a benefit, not only monstrating effectiveness. Nonetheless, we are
<br /> positive responsibility to engage in programs in terms of individual pleasure, but also in a pluralistic society, including with regard to
<br /> and interventions that seek to lessen societal terms of community cohesiveness. our notions of ethics. Different states and com-
<br /> inequalities, at the very least when those in- Solutions to these inevitable disagreements munities will decide differently which public
<br /> equalities relate (as essentially all do) to health must be reached through a system of fair pro- health activities are appropriate and which are
<br /> American Journal of Public Health I November 2001 , Vol 91 , No . 11 Kass Peer Reviewed Public Health Matters 1781
<br />
|