 PUBLIC HEALTH MATTERS 

An Ethics Framework for Public Health

| Nancy E. Kass, ScD

vital health statistics.2 Governments began

More than 100 years ago, public health began as an organized discipline, its purpose being to im-
conducting investigations of housing condi-
prove the health of populations rather than of individuals. Given its population-based focus, however,
tions and garbage heaps and mapping them
public health perennially faces dilemmas concerning the appropriate extent of its reach and whether in relation to outbreaks of disease,2 and by
its activities infringe on individual liberties in ethically troublesome ways. In this article a framework for the end of the 19th century, state and local
ethics analysis of public health programs is proposed. boards of health were being created to en-
To advance traditional public health goals while maximizing individual liberties and furthering so- force sanitary regulations.1(pp60–61)
cial justice, public health interventions should reduce morbidity or mortality; data must substantiate By the early 20th century, public health
that a program (or the series of programs of which a program is a part) will reduce morbidity or mor- was seen as cost-effective as well as useful,2
tality; burdens of the program must be identified and minimized; the program must be implemented and more money was directed to public
fairly and must, at times, minimize preexisting social injustices; and fair procedures must be used to health programs. During World War II, given
determine which burdens are acceptable to a community. (Am J Public Health. 2001;91:1776–1782) the need for a healthy population for the mili-
tary, the US Public Health Service established
the Center for Controlling Malaria in the War
Public health as an organized discipline began clinical practice and research. A first attempt Areas, later the Centers for Disease Control
more than 100 years ago, with the goal of im- at such a framework is offered here. and Prevention. Epidemiology developed as
proving the health, primarily, of populations the science of public health, to study “the dis-
rather than of individuals. Given its popula- PUBLIC HEALTH tribution and determinants of health-related
tion-based focus, however, public health con- states or events in defined populations and [to
tinually faces dilemmas concerning the appro- Public health is the societal approach to apply this knowledge] to the control of health
priate extent of its reach and at what point protecting and promoting health. Generally problems.”3(p42)
the work of public health professionals is in- through social, rather than individual, actions, Today, public health practitioners use
fringing on individual liberties in ethically public health seeks to improve the well-being tools in addition to epidemiology to accom-
troublesome ways. Nonetheless, there have of communities. By maintaining a safe water plish their work, still focusing primarily on
been few attempts to articulate an ethics of supply, immunizing schoolchildren, or engag- communitywide, typically prospective, ap-
public health. ing in epidemiologic research, public health proaches to improve health. Some public
Bioethics, as a discipline, helps health care seeks to ensure societal conditions under health functions—surveillance, vital statistics,
professionals identify and respond to moral which people can lead healthier lives,1 mini- disease and injury reporting, and disease
dilemmas in their work. In this article I sug- mizing threats to our health “that can be registries—relate to epidemiology and the
gest that the contexts out of which bioethics averted or lessened only through collective collection of data. In addition, practitioners
emerged—medical care and human research— actions aimed at the community.”1(p20) The investigate outbreaks, conduct contact trac-
were oriented toward a different set of con- providers of public health interventions often ing, provide health education and other pre-
cerns than those typically arising in public are governments, rather than private practi- ventive interventions, and conduct research
health. While the founders of bioethics articu- tioners. Indeed, the provision of health serv- related to public health. Last, public health
lated principles equally relevant for public ices, generally the domain of medicine, be- professionals sometimes create or enforce
health, the more specific action guides and comes the responsibility of public health health-related regulations and legislation, for
codes of health care ethics that have followed departments when services are provided by example, mandating screening, treatment,
are an imperfect fit for public health. Codes public clinics or hospitals. immunizations, or—rarely—quarantine.
of medical and research ethics generally give Public health interventions date back more States’ authority to pass laws to improve the
high priority to individual autonomy, a prior- than 3 centuries. In 1701, Massachusetts public’s health dates to the 19th century and
ity that cannot be assumed to be appropriate passed laws for isolation of smallpox patients is referred to as the “police power”: “coercive
for public health practice. and quarantine of ships.1(p57) In the early action under state authority to encourage edu-
A framework of ethics analysis geared 1800s, Edward Chadwick demonstrated in cational efforts . . . seize property, close busi-
specifically for public health is needed, both England that differences in social conditions nesses, destroy animals, or involuntarily treat
to provide practical guidance for public health led to a more than 2-fold difference in life ex- or even lock away individuals.”4(p42) These
professionals and to highlight the defining val- pectancy between upper and lower classes. various public health tools and functions,
ues of public health, values that differ in Also in the 1800s, Lemuel Shattuck, in Mass- while together successful in decreasing mor-
morally relevant ways from values that define achusetts, implemented the first system of bidity and mortality, nonetheless raise ques-

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tions of ethics in terms of the means by which viously, was now given preeminent moral We live in a morally pluralistic society, and
these successes are achieved. status.8–10 Informed consent, a practical ap- it is inevitable that moral appeals will conflict
plication of the autonomy principle, became when attempts are made to determine appro-
BIOETHICS AND PUBLIC HEALTH a hallmark of the new bioethics, and codes priate public policy. A framework for public
of ethics for clinical practice, while still em- health ethics will help public health profes-
Bioethics helps health professionals and phasizing the need not to harm the patient, sionals recognize the multiple and varied
public policymakers recognize moral dilem- added clauses requiring physicians to “best moral issues in their work and consider
mas in health care and biomedical research care for the dignity of man in patients or re- means of responding to them.
and provides principles and moral rules with search subjects.”11(p21)
which to navigate through these dilemmas. (A That contemporary medical ethics or re- AN ETHICS FRAMEWORK FOR
framework of bioethics based on principles, search codes have made the right to noninter- PUBLIC HEALTH
as put forward by Beauchamp and Childress,5 ference central is understandable, given the
will be used here. However, there are many context out of which they emerged. That pub- A 6-step framework is proposed for consid-
other bioethical frameworks, including, for ex- lic health practitioners, lacking guidelines of eration. Components of this framework were
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
based ethics.) professional moral direction, however, is framework was proposed for public health
Dating to the 1960s and 1970s, bioethics more problematic. In rare instances, existing and human rights by Gostin and Lazzarini.16
grew out of questions of fairness in resource medical or research codes do discuss tradi- This is not a code of professional ethics,
allocation, moral issues raised by new tech- tional public health functions, such as breach- which more likely would address general
nologies, and a lack of oversight in human- ing patient confidentiality to report diseases norms and expectations of professional be-
subjects research. The public was swept up to the state.12 In such instances, however, the havior and probably would be the product of
in debate about whether the first artificial physician’s behavior is presented as an allow- a professional society. Rather, this is an ana-
kidney center should allocate scarce re- able exception to usual ethics rules in the lytic tool, designed to help public health pro-
sources on the basis of social criteria and name of public health. fessionals consider the ethics implications of
whether Karen Ann Quinlan should be kept At best, this leaves public health profes- proposed interventions, policy proposals, re-
alive artificially when she had no meaningful sionals needing to muddle through most search initiatives, and programs.
cognition. other situations on their own; at worst, it
In 1969, the Institute of Society, Ethics, could lead them, or even the public, to as- 1. What are the public health goals of
and the Life Sciences (now the Hastings Cen- sume that public health is the branch of the proposed program?
ter) was created to address questions of health care sanctioned by bioethics to make The first step for any proposed public
bioethics and to provide frameworks with exceptions to existing ethics rules at will, in health program is to identify the program’s
which to analyze contemporary moral dilem- the name of public health and safety. In- goals. These goals generally ought to be ex-
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-
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-
research that compromised the rights and or framework of ethics designed specifically bidity or mortality. For example, an HIV
welfare of study subjects, a new national com- for public health is so very important. The screening program should have as its ulti-
mission issued the Belmont Report, which in- need for a code of ethics for public health, mate goal fewer incident cases of HIV, not
cluded ethics principles to guide the conduct then, might be viewed as a code of re- simply that a certain proportion of individu-
of human subjects research—beneficence, re- straint, a code to preserve fairly and appro- als will agree to be tested. A health education
spect for persons, and justice.7 Early framers priately the negative rights of citizens to program in cardiac risk reduction should
of bioethics elaborated on these principles noninterference. have as its ultimate goal (or the ultimate goal
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
ful in analyzing dilemmas from other areas of ethics must emphasize positive rights as well, individuals will have fewer heart attacks, not
health care, not just research.5 however. Public health has affirmative obli- simply that individuals will learn new infor-
These early framers argued that, a priori, gations to improve the public’s health and, mation or even that they will change their
no principle ought to have moral superiority arguably, to reduce certain social inequities. behavior. A research study should have as its
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
that animated bioethics in the early years— address such social justice functions of pub- trajectory of which it is a part) that findings,
the need to tell patients and research sub- lic health. While frameworks have been put if positive, will be implemented with the tar-
jects the truth, the patient’s right to refuse forward in medicine to help clinicians think get population and improve its health status.
care or research participation—were ones in through the ethical issues in a clinical While more proximate and process goals
which the principle of respect for autonomy, case,13,14 no analogous framework is avail- (such as whether individuals will learn
perhaps given too little moral attention pre- able for public health practitioners. health information or whether they will

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agree to be tested) are critical pieces of pro- According to this view, an intervention While many health education programs are
gram planning and evaluation and may be whose goal is to improve access to care very effective at transmitting information that
crucial to achieving health improvement, the among hard-to-reach populations has an ex- recipients learn and understand, programs
fundamental goal of decreased morbidity tremely relevant public health goal, assuming, generally are less successful at inducing be-
and mortality is the outcome by which the of course, the program is effective in improv- havior change.17,18 Thus, while a rather nar-
program or series of programs ultimately ing access. Other examples of interventions row evaluation may demonstrate success (in
must be assessed. This is not to say that designed to reduce social inequalities will be terms of participants’ understanding the mes-
each individual program or research study discussed further in step 5. sage), a program ultimately cannot claim suc-
must achieve this end. Epidemiologic studies Also relevant when we consider public cess if behavior is unaffected and morbidity
may provide descriptive data that lead sci- health goals and benefits is to whom the and mortality rates remain unchanged.
entists years later to develop an intervention benefit will accrue. Public health interven- This is not to suggest that each program
that will result in a reduction in morbidity tions often are targeted to one set of individ- must reduce morbidity by itself. Individual
or mortality; a health education program uals to protect other citizens’ health. Partner health education or screening programs, for
may be one of multiple and varied interven- notification programs and directly observed example, might be pieces of larger initiatives
tions that together reduce risks and ill therapy for tuberculosis are designed prima- to reduce cardiac morbidity and mortality.
health. The argument put forth here, how- rily to protect citizens from the health Data may show that multiple education cam-
ever, is that public health programs, inter- threats posed by others. In some contexts, paigns in different formats and with different
ventions, or studies must be designed with public health programs are designed prima- messages are required to induce widespread
an awareness of the relationship between rily to protect individuals from themselves, behavior change. Multidimensional efforts are
this program and an ultimate reduction in revealing that much of public health is inher- appropriate and useful, if data show that the
morbidity or mortality. ently and unabashedly paternalistic. Health combination is likely to evoke the desired re-
Of course, other types of benefits, gener- education campaigns, blood pressure screen- sult. Again, however, if the multiple ap-
ally social benefits, can accrue from public ing, seat belt laws, and 55-mile-per-hour proaches are simply hypothesized or assumed
health programs as well. Public health pro- speed limits, while motivated in part by so- to reduce illness events, then further research
grams can result in greater employment, for cial concerns about costs, are, I suggest, mo- must be done; a public health program is not
example, as well as less tangible benefits, tivated primarily to further individuals’ abil- yet justified.
such as coalition-building or the strengthen- ity to protect their own health. Restricting This step of examining existing data to
ing of communities. These benefits are ex- someone’s liberty to protect him- or herself challenge our assumptions and implement
tremely important and should be given and restricting liberty to protect another per- only data-based policies or programs is often
strong consideration. They are, however, the son pose different ethical burdens, discussed neglected in public health. One can assume
incidental or intermediary outcomes of pub- further in step 3. that this is not because professionals are indif-
lic health programs, rather than the pro- ferent to whether their methods relate to
grams’ final goal. If a program has as its goal 2. How effective is the program in their outcomes, but because we simply as-
to increase employment as an end in itself achieving its stated goals? sume that they do, and we neglect to find
(rather than, for example, to increase employ- Proposed interventions or programs are data that prove us right or wrong. Thus, we
ment as a means to lower psychological mor- based on certain assumptions that lead us to introduce a program based on the assumption
bidity or as a means to improve socioeco- believe the programs will achieve their stated that some number of people who learn that
nomic status and therefore lead to improved goals. Step 2 asks us to examine what those cigarettes cause asthma and lung cancer will
health) or to strengthen communities (rather assumptions are and what data exist to sub- quit smoking, or we call for HIV screening
than to strengthen communities as a means stantiate each of them. A cardiac risk reduc- because we assume that individuals who
to decrease interpersonal violence or as a tion program has as its ultimate goal the re- learn they are infected will begin to use con-
means to help watch out for the well-being of duction of fatal and nonfatal cardiac events. doms in sexual relationships. It is when our
the young or old persons in the community), The assumptions of this education program assumptions seem most intuitively obvious
then the program is primarily a social pro- (or the larger effort of which it is a piece) are that we are at greatest risk of neglecting to
gram, not a public health program. that the program will reach individuals at risk determine to what extent they are supported
As described further below, a reduction in for cardiac events; those individuals will learn by real evidence.
morbidity and mortality need not and could the risk reduction messages; individuals will While all programs must be based on
not be the goal of every individual public change their behavior (e.g., stop smoking, sound data rather than informed speculation,
health intervention or program; however, in- change diets, increase exercise) in ways sug- the quality and volume of existing data will
dividual public health programs should not be gested by the program; these changes would vary. The question for policy and ethics anal-
undertaken that are not part of a larger pack- not have occurred without the program; and ysis, then, is what quantity of data is enough
age of programs whose combined goal is the the behavior change in itself will result in to justify a program’s implementation? As a
reduction of morbidity and mortality. fewer cardiac events. rule of thumb, the greater the burdens posed

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by a program—for example, in terms of cost, about ethnic groups or neighborhoods that not able to decide for themselves whether to
constraints on liberty, or targeting particular, may be stigmatizing or otherwise harmful. release their names to officials. As stated
already vulnerable segments of the popula- Communicable disease reporting raises pri- above, harms can occur if confidentiality pro-
tion—the stronger the evidence must be to vacy concerns as well, but the infringement tections fail, and individuals can feel wronged
demonstrate that the program will achieve its and risks potentially are greater, since names simply by virtue of the violation of their pri-
goals. Indeed, because many public health are reported only of those who have re- vacy. Justice concerns also arise if contact
programs are imposed on people by govern- portable (and often socially stigmatizing) tracing programs are not implemented fairly.
ments and not sought out by citizens, the bur- conditions. Given that individuals typically Health education poses interesting questions
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-
health practitioners to prove that the program whom private information is disclosed, dis- cation is the ideal public health intervention,
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
data do not exist that demonstrate the validity breach of confidentiality if security measures empower people to make their own decisions
of a program’s assumptions, the analysis can are not followed or do not work. For some, regarding their health once they are equipped
stop right here, and, ethically, the program there is a risk of privacy infringement only with accurate information. From an ethics
should not be implemented. Conversely, the to the extent that confidentiality is not main- perspective, education clearly is preferable to
presence of good data alone does not justify tained and harms such as social stigma or other preventive strategies, to the extent that
the program; it allows us to move to the next loss of employment ensue from unwarranted they are equally effective, because it poses
stage of the analysis. disclosure. For others, the privacy infringe- few, if any, burdens.
ment is viewed as a wrong in itself, regard- Health education, however, although an es-
3. What are the known or potential less of whether any tangible harm ensues. sential component of most public health cam-
burdens of the program? Disease reporting is an example of a public paigns, will not be appropriate for all situa-
If data suggest that a program is reasonably health function that, at least on its face, is dis- tions. First, education may not work in all
likely to achieve its stated goals, then the tributionally unfair, in that the burdens of the settings, and more burdensome measures
third step of the framework asks us to identify program are borne by those with the disease, may be required. Second, to increase effec-
burdens or harms that could occur through generally for the benefit of others who do not tiveness, educational programs may introduce
our public health work. have the disease. This unevenness of burdens ethically questionable practices, such as ma-
Although a variety of burdens or harms and benefits may be justified in certain in- nipulation or even coercion. A smoking cessa-
might exist in public health programs, the ma- stances, when the benefits are important and tion program, for example, may try to manip-
jority will fall into 3 broad categories: risks to when there are no less burdensome ways to ulate attitudes by suggesting that smokers are
privacy and confidentiality, especially in data achieve them. Unevenness in benefits and unpopular and by providing only partial or
collection activities; risks to liberty and self- burdens is never appropriate, however, if even false information to achieve its ends.20
determination, given the power accorded groups are burdened in ways that are arbi- Third, all health education campaigns are
public health to enact almost any measure trary and without public health justification. potentially paternalistic, suggesting that cer-
necessary to contain disease; and risks to jus- Further, a program that does not target partic- tain ways of being (e.g., in greater aerobic
tice, if public health practitioners propose tar- ular groups explicitly may, in fact, lead to tar- health) are universally valued. Additional
geting public health interventions only to cer- geting in its implementation. One study, for work is needed to examine when and where
tain groups. Different types of burdens are example, suggested that doctors are more paternalism in public health is justified, es-
more or less likely to result from different likely to report a patient with HIV to the pecially since biomedical ethics generally
types of public health activities. health department if the patient is Black and has steered professionals away from pater-
Disease surveillance and vital statistics, de- male,19 despite language in the statute requir- nalism except when it is specifically re-
signed to monitor health and population ing the reporting of all persons with HIV. The quested by patients. (See Bernard Lo for a
trends, raise potential privacy concerns, espe- appropriateness of creating targeted public discussion of paternalism in which he con-
cially since data collection is mandatory and health programs justified by epidemiologic cludes that “when disagreements persist
data often are individually identifiable and, in data is discussed further in step 6. after repeated discussions, the patient’s in-
many cases, publicly available. Although the Contact tracing, which sometimes accompa- formed choices and definition of best inter-
types of data collected are not considered nies communicable disease reporting, poses ests should prevail,”21[pp39–43] and a discus-
very personal or sensitive by most persons, additional privacy risks. Not only are an indi- sion of patients who do not want to make
everyone has his or her own boundary of pri- vidual’s name and condition reported, but in- their own decisions.21[p29])
vacy. Further, for some individuals, particular dividuals are asked to provide the names of Fourth, health education programs may tar-
elements of vital statistics, such as paternity or other (usually sexual) contacts they have had. get messages to certain audiences. Although
cause of death, could be seen as invasions of Obviously a privacy infringement in itself, such targeting is often justified on public
their privacy. Finally, vital statistics and other contact tracing also invades the privacy of in- health grounds (e.g., epidemiologic data dem-
publicly collected data can reveal patterns dividuals whose names are disclosed, who are onstrate that members of this population are

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at greatest risk, so their pictures will go on the Regulations and legislation, strictly speaking, tact tracing programs, strictly speaking, are
billboards and messages will be promoted on are coercive, since they impose penalties for voluntary, in that no sanctions are imposed
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-
and even public health ramifications of target- erty and self-governance. While many of these cally incumbent on public health practitioners
ing must be seriously considered. Social measures, such as reduced speed limits, child- to inform individuals sought for contact trac-
stigma can result if, for example, certain sub- proof bottles, and immunization, have demon- ing of their right to refuse to disclose the
groups of the population are assumed to be strated efficacy, they nonetheless are the most names of their partners, as well as of their
the ones who carry sexually transmitted dis- intrusive approach to public health. Edmund right to inform partners themselves, have a
eases, and opportunities for public health in- Pellegrino and David C. Thomasma write: known health care provider do it, or have
tervention will be missed entirely if we all Involuntary and coercive measures must be partners contacted by an agent of the state.
come to believe, through well-intentioned undertaken with a clear perception of the dan- If 2 options exist to address a public health
media campaigns, that only certain groups are gers they pose to a democratic society: loss of problem, we are required, ethically, to choose
personal freedom to choose a lifestyle, depen-
at risk for domestic violence or HIV. dence upon governments to define values and the approach that poses fewer risks to other
Finally, health education campaigns may concepts of the good life, and the imposition of moral claims, such as liberty, privacy, oppor-
be accompanied by incentives. Incentives gen- cultural homogeneity. Involuntary measures tunity, and justice, assuming benefits are not
also assume a benign, wise, and responsive
erally are considered ethically less problem- government—something history finds singularly significantly reduced. Making this assessment
atic than coercive measures or threats, but rare.10(p375) relies on the existence of sound data. If data
even incentives could be ethically question- show that a voluntary screening program will
While threats to autonomy are the most
able in certain contexts, such as when finan- test essentially the same number of individu-
obvious threats posed by public health regu-
cial incentives are given for using particular als as a mandatory one, because almost no
lations and legislation, such regulations and
types of birth control or avoiding pregnancy.22 one refuses testing when asked, then it would
legislation can, in some circumstances, be as-
Public health research carries burdens. Hu- be ethically improper to implement a manda-
sociated with physical risks, or risks to indi-
man subjects regulations already describe the tory program.23(chap6) If disease surveillance is
viduals’ health, as well. Federally approved
types of harms that could occur through re- equally effective with unique identifiers or
and mandated vaccinations carry health risks
search participation. These include medical with names, a program of unique identifiers is
to individuals; widespread spraying to pre-
risks if the research is clinical, and psycholog- the morally preferable choice.
vent the spread of mosquito-borne viruses
ical or social risks if the research is epidemio-
can cause proximate health problems to
logic or social science. In recent years there 5. Is the program implemented fairly?
some individuals who inhale the chemicals.
has also been increased attention to the per- This piece of the framework corresponds to
Finally, in this instance as well, the law can
sonal and social burdens that can result from the ethics principle of distributive justice, re-
impose, by design or inadvertently, threats to
injustice or exploitation in research when quiring the fair distribution of benefits and
justice if regulations impose undue burdens
certain populations are disproportionately burdens.5(pp326–394) Public health benefits,
on particular segments of society.
disadvantaged or privileged through research such as clean water, cannot be limited to one
participation. 4. Can burdens be minimized? Are there community, nor can a single population be
In addition to these well-articulated risks, alternative approaches? subjected to disproportionate burdens. HIV
however, is the harm that can occur if public This piece of the framework requires us to screening programs, for example, cannot be
health research findings are never imple- minimize burdens once they have been identi- implemented only in poor or minority com-
mented in public health policy or practice. fied. If step 3 suggests that a program or policy munities without strong justification (see Stoto
Any study conducted imposes, at the very carries potential or actual burdens, we are ethi- et al.23 for a discussion of why universal HIV
least, the burden of inconvenience on those cally required to determine whether the pro- screening programs are ethically preferable to
who participate, and may, of course, pose gram could be modified in ways that minimize targeted programs); cardiac risk reduction
more significant risks to the individuals or the burdens while not greatly reducing the programs cannot be targeted exclusively to
communities who volunteer. An institutional program’s efficacy. Public health professionals, White men when women and minorities are
review board allows research to go forward for example, when ready to report a patient’s also at substantial risk of heart disease.
because of the benefits expected to emerge name and disease to the state, should inform That programs be implemented fairly is
from study findings. If research findings are patients that their names, by law, must be re- even more important if restrictive measures
never translated into policy, however—a situa- ported to public health authorities but that the are proposed. Injustice is wrong for its own
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
crue from the research. In such instances, par- dentially. Although reporting programs are not evoke. Social harms result if social stereo-
ticipants were wronged through a misleading optional, the policy is more respectful of pa- types are created or perpetuated, such as the
(albeit not deliberately so) informed consent tients if patients are adequately informed. stereotype that only certain segments of the
process, and the risk-to-benefit ratio could Contact tracing programs, similarly, pose population are vulnerable to sexually trans-
rarely be considered favorable. threats to privacy and confidentiality. Yet con- mitted diseases. In addition, real public health

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harms result when individuals do not believe outcomes. Indeed, it is hard to find a more cedures. Procedural justice requires a society
that they are at risk for disease because they powerful predictor of health than class,28,29 to engage in a democratic process to deter-
were never targeted in education campaigns, and it is thus an appropriate, if not obligatory, mine which public health functions it wants
or because their own doctors never screened function of public health to reduce poverty, its government to maintain, recognizing that
them for a condition because they didn’t fit substandard housing conditions, and threats some infringements of liberty and other bur-
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
that programs or resources must be allocated son than to reduce the incidence of disease. discussion of what a society gains from good
equally to all communities—rather, the alloca- public health and why such benefits often
tions must be fair. That is, differences cannot 6. How can the benefits and burdens of cannot be obtained through less communal or
be proposed arbitrarily or on the basis of his- a program be fairly balanced? more liberty-preserving methods. The discus-
torical assumptions about who might be at If it is determined that a proposed public sion, of course, should also address why other
risk. Again, unequal distributions of programs health intervention, policy, or program is interests also have moral claim. Such a pro-
must be justified with data. Moreover, the so- likely to achieve its stated goals, if its poten- cess, even when procedurally fair by most
cial consequences must be considered if a tial burdens are recognized and minimized, standards, must not result in decisions based
community is allotted resources unequally, and if the program is expected to be imple- solely on the will of the majority. Indeed, de-
and these consequences must be balanced mented in a nondiscriminatory way, a deci- liberations, particularly around significantly
against the benefits to that community or sion must be reached about whether the ex- burdensome proposals, must be scrutinized to
others. pected benefits justify the identified burdens. ensure that the views of the minority are
Discussed less frequently is whether, or the Recognizing, of course, that public policy is given due consideration. Highly burdensome
degree to which, public health has any ex- based on multiple considerations in addition programs should be preceded by public hear-
plicit role in righting existing injustices, espe- to ethics, the question must still be asked ings, not just votes, so that minority views can
cially given the strong link between poor liv- whether, from an ethics perspective, the pro- be heard and considered.
ing conditions and poor health outcomes. To gram should go forward. Health department At the same time, it is important to ac-
what extent is there a positive responsibility officials and other public health professionals knowledge that there will always be some
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
advocate better housing, better jobs, and bet- grams they think would be beneficial, but water fluoridated, do not want their children
ter access to food programs, since such advo- they do have a responsibility both to advo- immunized, do not want to wear seat belts,
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.
public’s health? remove from policy debate programs that are That there is dissent is insufficient justification
Several notions of justice allow and even unethical, whether because of insufficient for blocking a public health program; indeed,
require unequal allocation of benefits to right data, clearly discriminatory procedures, or un- dissent is inevitable in all proposals. Dissent
existing inequities. John Rawls posits that jus- justified limitations on personal liberties. must be considered, however, and it deserves
tice requires us to allocate our resources un- And yet while most reasonable people will special attention if it is raised exclusively by a
equally to help the least well-off.25 Norman agree, in the abstract, that burdens and bene- particular identified subgroup such as an eth-
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-
society to be brought to a level of “species- densome programs should be implemented dents of a particular neighborhood.
typical normal functioning,”26 which also only in the context of extensive and impor- In balancing values and interests, the greater
could result in the unequal distribution of cer- tant benefits, disagreements are all but guar- the burden imposed by a program, the greater
tain resources. Admittedly, not all philoso- anteed over the details. Depending on one’s must be the expected public health benefit,
phers have adopted this notion of justice; perspective, there will be differing views over and the more uneven the benefits and burdens
some make a distinction between preexisting how burdensome various programs are, such (that is, burdens are imposed on one group to
societal inequities that are unfair (because as having one’s name reported to the state or protect the health of another), the greater must
they resulted from a person or community being required to immunize children before be the expected benefit. Programs that are co-
having been wronged by an identifiable they start school. Citizens can be expected to ercive should be kept to a minimum, should
source), where intervention is owed, and in- differ over how important it is to protect a never be implemented when a less restrictive
equities that are merely unfortunate (that is, water supply for future generations, particu- program would achieve comparable goals, and
due to acts of God or circumstance), where larly if it means significantly higher taxes or should be implemented only in the face of
no intervention is morally required.27 prohibiting recreational use of a public body clear public health need and good data de-
Public health, I would argue, does have a of water—which is clearly a benefit, not only monstrating effectiveness. Nonetheless, we are
positive responsibility to engage in programs in terms of individual pleasure, but also in a pluralistic society, including with regard to
and interventions that seek to lessen societal terms of community cohesiveness. our notions of ethics. Different states and com-
inequalities, at the very least when those in- Solutions to these inevitable disagreements munities will decide differently which public
equalities relate (as essentially all do) to health must be reached through a system of fair pro- health activities are appropriate and which are

American Journal of Public Health | November 2001, Vol 91, No. 11 Kass | Peer Reviewed | Public Health Matters | 1781
  PUBLIC HEALTH MATTERS 

overly burdensome. Ultimately, that different reasonable to assume that the public will be 10. Pellegrino E, Thomasma DC. For the Patient’s
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About the Author programs and their implications for women. Duke Jour-
but it may not lead to the politically prefer- Nancy E. Kass is with the Department of Health Policy
nal of Gender Law & Policy. 1998;5(1):89–102.
able option for a given time. That politics and Management, Johns Hopkins School of Public Health,
and the Johns Hopkins University Bioethics Institute, Balti- 16. Gostin LO, Lazzarini Z. Human Rights and Public
often takes a divergent and somewhat unpre- Health in the AIDS Pandemic. New York, NY: Oxford
more, Md.
dictable path, however, is not an excuse for Requests for reprints should be sent to Nancy E. Kass, University Press; 1997.
abandoning ethics analysis when a public ScD, Hampton House 344, 624 N Broadway, Baltimore, 17. Glanz K, Lewis FM, Rimer BK, eds. Health Behav-
MD 21205 (e-mail: [email protected]). ior and Health Education: Theory, Research, and Practice.
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This article was accepted February 23, 2001. 2nd ed. San Francisco, Calif: Jossey-Bass Publishers;
analysis must always be conducted, both be- 1996.
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Acknowledgments
our work is right in itself and also because, I would like to thank the Johns Hopkins School of Pub- Svarstad B. Effectiveness of interventions to improve
patient compliance: a meta-analysis. Med Care. 1998;
from a more utilitarian perspective, public lic Health for funding a sabbatical during which early
drafts of this article were written, and Dr Bernie Lo and 36:1138–1161.
health work will be more effective if we do.
colleagues for hosting me during the sabbatical and cri- 19. Schwartzbaum JA, Wheat JR, Norton RW. Physi-
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
makes us meticulous in our reasoning, requir- Dr Ruth Faden, and anonymous reviewers whose com- with human immunodeficiency virus (HIV) infection:
ments improved the final version. patterns of decision. Am J Public Health. 1990;80:
ing us to advocate interventions on the basis of
829–834.
facts and not merely belief. Further, an ethics
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1782 | Public Health Matters | Peer Reviewed | Kass American Journal of Public Health | November 2001, Vol 91, No. 11
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