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PUBLIC HEALTH MATTERS
<br /> overly burdensome. Ultimately, that different reasonable to assume that the public will be 10. Pellegrino E, Thomasma DC. For the Patients
<br /> communities will enact different public poli- concerned about which functions are neces- Good: The Restoration ojn v Beneficence P in Health Care
<br /> New York, NY: Oxford University Press; 1988.
<br /> ties, based on their own balancing of benefits sary and which are overly burdensome, offen
<br /> 11 . Ramsey P. The nature of medical ethics. In:
<br /> and burdens, may be indicative of a fair pro- sive, or simply wasteful. This process, then, Veatch RM, Gaylin W, Morgan C, eds. National Confer-
<br /> cess, or at least a pluralistic, process, steering must be integrated, constant, and ongoing. ence on the Teaching of Medical Ethics. New York, NY:
<br /> local public health policy. The most important asset that public health Hastings Center; 1973: 14-28.
<br /> can have is the public's trust that work is 12. AMA PolicyFindec Current Opinions of the Coun-
<br /> cil on Ethical and judicial Affairs, E-2.23. HIV Testing.
<br /> CONCLUSION being done on its own behalf. In such a con- Available at: http://www.aina-assn.org/ad*com/polfind/
<br /> text, public health professionals can and must amocmce.htin. Accessed September 2, 2001 .
<br /> Of course, public policy is based on many advocate what they believe, on balance, are 13. McCullough LB, Ashton CM. A methodology for
<br /> factors in addition to public health goals and the ethically best approaches for furthering so- teaching ethics in the clinical setting: a clinical hand-
<br /> book for medical ethics. 7heor Med 1994; 15( 1):39-52.
<br /> ethical reasoning. Weighing alternatives ac- cial justice and the public's health. â– 14. Jonsen A, Siegler M, Wmslade W. Clinical Ethics.
<br /> cording to this public health ethics framework 2nd ed. New York, NY: Macmillan Publishing Co; 1982.
<br /> should lead to an ethically acceptable option, About the Author 15. Kass NE, Gielen A. The ethics of contact pacing
<br /> but it may not lead to the politically prefer- Nancy E. Kass is with the Department of Health Policy Programs and their hnplic 199 for women. DukeJour-
<br /> able option for a given time. That politics and Management, Johns Hopkins School of Public Health, nal of Gender Law & Policy. 1998;5(1 ):89-102.
<br /> often takes a divergent and somewhat un re and theJohns Hopkins University Bioethics Institute, Balti- 16, Gostin LO, Lazzarvri Z. Human Rights and Public
<br /> g p more, Md. Health in the AIDS Pandemic. New York, NY: Oxford
<br /> dictable path, however, is not an excuse for Requests for reprints should be sent to Nancy E. Kass, University Press; 1997.
<br /> abandoning ethics analysis when a public SeD, Hampton House 344, 624 NBroadway, Baltimore, 17. Glanz K, Lewis FM, Rimer BY, eds. Health Behav-
<br /> health proposal is up for discussion. An ethics MD 21205 (e-mail: nkassejhsph.edu). for and Health Education: Theory, Research, and Practice.
<br /> This article was accepted February 23, 2001. 2nd ed. San Francisco, Calif: Jossey-Bass Publishers;
<br /> analysis must always be conducted, both be- 1996,
<br /> cause bringing truth, fairness, and respect to Acknowledgments 18. Roter DL, Hall JA, Merisca R, Ruehle B, Cretin D,
<br /> our work is right in itself and also because, I would Lice to thank the Johns Hopkins School of Pub- Svarstad B. Effectiveness of interventions to improve
<br /> from a more utilitarian perspective, public lie Health for funding a sabbatical during which early patient compliance: a meta-analysis. Med Care. 1998;
<br /> health work will be more effective if we do.
<br /> chaffs of this article were written, and Dr Bernie Lo and 36: 1138-1161.
<br /> colleagues for hosting me during the sabbatical and trim 19. Srhwartzbaum JA, Wheat JR, Norton RW. Physi-
<br /> Engaging in the steps of an ethics analysis tiquing an earlier draft. Thanks also to Dr Susan Rubin, cian breach of patient confidentiality among individuals
<br /> makes us meticulous in our reasoning, requir- Dr Ruth Faden, and anonymous reviewers whose cony with human immunodeficiency virus (HIV) infection:
<br /> ing us to advocate interventions on the basis of ments improved the final version. patterns of decision. Am J Public Health. 1990;80:
<br /> 829-834s
<br /> facts and not merely belief. Further, an ethics References 20. Willer DI. Ethical Issues in Governmental Efforts to
<br /> analysis holds us to high standards, not only 1 . Institute of Medicine. The Future of Public HealthPromote Health. Washington, DC: National Academy of
<br /> for scientific method but also for how respect Washington, DC: National Academy Press; 1988. Sciences; 1978:25.
<br /> 21.fully we communicate with and involve con- 2. Fee E. History and development of public health. La Resolving Ethical Dilemmas: A Guide jot
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<br /> stituent communities. The involvement of comm In: Scutchfield FD, Keck CW, eds. Principles of Public Clinicianss.. Baltimore, Md: Williams & Wilkins; 1995.
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<br /> munities will help identify the public health 1977: 10-30. Health Programs: An Ethical Framework. Berkeley:
<br /> threats divergent groups face and will create, if School of Public Health, University of California at
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<br /> not partnerships, at least-one can hope-a ream New York, NY: Oxford University Press; 1988.
<br /> Re
<br /> sonable amount of Lust. To succeed, the field du g theoto OddMA, Ahnario ng McCormick MC, eds. f
<br /> 4. Richards EP, Rathbun KC. The legal basis for dicing the Odds: Preventing i3?rinatal 7iansmission of
<br /> of public health must gain the public's trust public health. In: Scutchfield FD, Keck CW, eds. Princi- HIV in the United States. Washington, DC: National
<br /> that the inevitable higher proportions of gov- pies of Prcblic Health Practice. Boston, Mass: Delmar Academy Press; 1999.
<br /> Publishers; 1977:42-54. 24. Kass NE. Gender and health research. In: Kahn ,
<br /> ernment involvement and population targeting J
<br /> imposed by public health, relative to other 5. Beauchamp TL, Childress JL. Principles of Biomed- Mashoianni A, Sugarman J, eds. Beyond Consent Justice
<br /> ical Ethics. New York, NY: Oxford University Press; in Research. New York, NY: Oxford University Press;
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<br /> these various communities' best interests. 6. Callahan D. Bioethics as a discipline. Hastings 25. Rawls J. A Theory ofjustice. Cambridge, Mass: The
<br /> Public health professionals must go through Center Stud. 1973;1 :66-73. Belknap Press of Harvard University Press; 1971 .
<br /> the steps of an ethics analysis to assure the 7. National Commission for the Protection of Human 26. Daniels N. Just Health Care Cambridge, England:
<br /> public of their integrity. The public must feel Subjects of Biomedical and Behavioral Research. The Cambridge University Press; 1985. Studies in Philoso-
<br /> Belmont Report: ethical principles and guidelines for phy and Health Policy.
<br /> confident that public health professionals will the protection of human subjects of research. Washing• 27. Engelhort T. The Foundations of Biomedical Ethics.
<br /> offer only those proposals that will improve ton, DC: US Dept Of Health, Education, and Welfare; New York, NY: Oxford University Press; 1986.
<br /> the health of the public, that proposed mea- April 18, 1979. Available at: http://ohsrod.nih.gov/ 28. Adler NE, Marmot M, McEwen BS, Stewart J, eds.
<br /> mpa/belmontphp3. Accessed August 8, 2001 . Socioeconomic Status and Health in Industrial Nations:
<br /> sires are minimally burdensome, and that a
<br /> 8. Callahan D. Autonomy: a moral good, not a moral Social, Psychological, and Biological Pathways. New
<br /> fair procedure has determined that the magni- obsession. Hastings Center Rep. 1984; 14(5):40-42. York, NY: New York Academy of Sciences; 1999.
<br /> tulle of the problem and the ensuing benefits 9. Steinbock B. Liberty, responsibility, and the cony- 29. Wilkinson RG. Unhealthy Societies: The Afflictions
<br /> justify overriding conflicting moral claims. It is mon good. Hastings Center Rep. 1996;26(6):45-47. ojlnequalily. London, England: Roudedge; 1996.
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