Many of us have just returned from the edifying and inspiring sessions and events of the 2006 Annual Meeting in Boston whose theme was “Public Health and Human Rights.” I hope it inspired you to delve more deeply into this topic, of late as provocative in world politics as it is timely in public health. It raises a wide range of issues in public health ethics, and here are some resources I recommend for your reading.[i]
Ever since its publication eight years ago, I’ve appreciated New Ethics for the Public’s Health, edited by Dan E. Beauchamp and Bonnie Steinbock (Oxford University Press, 1999) for its broadly literate and philosophical treatment of its subject. Its editors chose 29 readings that reflect conceptual and policy challenges to the practice of public health, and organized them under nine sections, providing each with a discursive overview that identified the issues covered and provided a context for seeing how the selections fit into the unique community perspective of public health.
Oxford University Press is now publishing a revised edition under the title, Public Health Ethics: Theory, Policy, and Practice, edited by Ronald Bayer, Lawrence O. Gostin, Bruce Jennings, and Bonnie Steinbock. It includes 25 mostly new readings under six sections, each prefaced by an introductory essay. The strength of this approach is to make accessible a set of readings representing paradigms of reasoning on key public health issues, not polemics. The excellent general introduction by Beauchamp and Steinbock from the original book is reprinted with minor changes.
Among the new readings included is one that is must reading for anyone concerned with the future of public health: “The Future of the Public’s Health: Vision, Values, and Strategies,” by Lawrence O. Gostin, Jo Ivey Boufford, and Rose Marie Martinez (Health Affairs 23: July/August 2004, 96-107).
The moral dimensions of public health practice are best appreciated through examination of difficult cases. The task facing public health is a practical one of exercising good judgment about the needs of populations in particular contexts, and that judgment and the insight needed for it is best developed through the examination of real cases in which the choice among alternative courses of action can be seen more clearly than the choice among alternative ethical theories. The right thing to do is then seen as contained in one’s understanding of the particulars of the case. This places priority on life wisdom about good actions – what one ought to do (Aristotle’s praxis) – over knowledge derived from theories.
The tensions in our society that afflict the practice of public health reflect the age-old opposition between the individual and society that concerns political and ethical theory. So for a public health ethic, we must look to the ideology that governs our political thought, and that is liberalism.
At the foundation of the liberal political tradition is the idea that a person has a dignity and worth that social structures should not be permitted to violate. It was the core value in the political philosophy of John Locke and David Hume, and in the moral philosophy of Immanuel Kant, and it is reflected in medical ethics. American devotion to individualism is reflected in the concept of market-justice. But the liberal tradition also promotes social justice, and this is increasingly being seen as the core value in the mission of public health, one opposed to market-justice. It seeks the fair and equitable distribution of both the benefits and the burdens of the society.[ii]
And that was the prevailing political ethic in this country for much of the past century, the one responsible for Social Security, Medicare, and Medicaid. For, in the words of President Franklin Delano Roosevelt (Second Inaugural Address, 1937), “The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little,” followed a generation later by President John F. Kennedy’s, “If a free society cannot help the many who are poor, it cannot save the few who are rich.”
One of Hubert Humphrey's speeches contained the lines "It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped."
The task of moral and political philosophers has been to reconcile these sometimes conflicting themes in medical and public health practice, in individual liberties and social demands, a task well stated in an AJPH article by Daniel Callahan and Bruce Jennings:
"It is one thing to say that public health rests on a communitarian foundation and quite another to determine how best to relate that foundation to our individualist culture, particularly in that members of this culture have been historically hostile toward government. The conflict, long endemic in our society, between the right of individuals to be left alone and the needs of the larger public does not make it easy to develop population-based health strategies that must, on occasion, ignore the special needs of individuals".[iii]
The philosophical approach that best exemplifies the liberal heritage was fully developed in John Rawls’ A Theory of Justice (Harvard University Press, 1971). In it, he operationalized a process for determining moral judgments based on our intuitive sense of fairness, a kind of “procedural justice,” that squares individual freedoms with social needs. Through it, he restablished the tradition of setting political deliberation on a foundation of moral argument. His “first principle of justice” neatly expresses the liberal view of the aim of government: “Each person is to have an equal right to the most extensive total system of equal basic liberties compatible with a similar system for all.” (p. 302)
Aristotle saw that ethics is a branch of politics. Public health is part of government, and like government, just what it is will be continually redefined by politics and public policy. The oft-quoted mission offered by the Institute of Medicine in its The Future of Public Health (1988) – “fulfilling society’s interest in assuring conditions in which people can be healthy” – is the role of government, not of public health.[iv] In the WHO’s World Health Report 2000, its Director-General, Dr. Gro Harlem Brundtland, stated explicitly that “the careful and responsible management of the well-being of the population – stewardship – is the very essence of government.” The late Jonathan Mann observed that people cannot be healthy if governments do not respect their rights and dignity as well as engage in health policies guided by sound ethical values. And so in seeking the best ground for the ethics of public health, I think we need to look to the very best in public policy, and that is human rights.
Human rights reflect ethical principles, incorporated into national and international legal systems, governing respect for the dignity, integrity, autonomy, and freedom of persons. Writing from the perspective of history, Arthur M. Schlesinger, Jr. labeled them “roughly the idea that all individuals everywhere are entitled to life, liberty and the pursuit of happiness on this earth.”[v] Integral to health as a human right is recognition of the right to the essential social determinants of health and well-being, and deprivation of these rights has been shown by social epidemiology to be a barrier to good health defined as physical, mental and social well-being. Therefore, the aims of public health in assuring conditions in which people can be healthy require it to embrace the universally recognized standards for human rights adopted in 1948 by the United Nations as the Universal Declaration of Human Rights.[vi] Jonathan Mann believed that the promotion and protection of health and human rights are “inextricably linked.” Human rights violations adversely affect the community's health, coercive public health policies violate human rights, and advancement of human rights and public health reinforce one another. Unfortunately, in our schools of public health, courses in human rights are even scarcer than courses in public health ethics.[vii]
Dr. Albert Schweitzer believed it to be an ethical imperative for physicians to serve where most needed, and unless physicians in training serve in public health settings, they will never understand why. And I think that medical practice suffers when medical ethics is taught in medical schools without reference to global health. Dr. Paul E. Farmer, Keynote Speaker at our Boston Conference, writes that, “without a social justice component, medical ethics risks becoming yet another strategy for managing inequality,” and "equity is the central challenge for the future of medicine and public health.”[viii]
by John Steen
Consultant in Health Planning, Health Regulation, and Public Health
1 The relevance of this theme was well presented in an editorial by Rosalia Rodriguez-Garcia and Mohammad N. Akhter in the May 2000 issue of the American Journal of Public Health: http://www.ajph.org/cgi/reprint/90/5/693.pdf.
2 For an excellent article that explores how social justice sheds light on major ongoing controversies in the field of public health, see “What Does Social Justice Require for the Public’s Health? Public Health Ethics and Policy Imperatives,” by Lawrence O. Gostin and Madison Powers. Health Affairs, 25, no. 4 (2006): 1053-1060, and Social Justice: The Moral Foundations of Public Health and Health Policy
by Madison Powers and Ruth Faden (Oxford University Press, 2006).
3 “Ethics and Public Health: Forging a Strong Relationship,” Daniel Callahan and Bruce Jennings, AJPH, Vol 92, No. 2 (February 2002). 169-176. The authors provide a timely overview of the relationship, and well-considered recommendations for what more is needed.
4 For a brief summary of all the things we might expect of our government here, see “What the federal government can do about the nonmedical determinants of health,” by Nicole Lurie, Health Affairs, Vol 21, Issue 2, (March/April 2002) 94-106.
5 “Human Rights and the American Tradition,” Foreign Affairs, Vol. 57, Number 3 (1978). http://www.foreignaffairs.org/19790201faessay9904/arthur-m-schlesinger-jr/human-rights-and-the-american-tradition.html.
6 Available at http://www.un.org/Overview/rights.html.
7 Nine years ago, APHA adopted Policy Statement #9813 promoting “Human Rights in the Curricula of Health Professionals.” http://www.apha.org/legislative/policy/policysearch/index.cfm?fuseaction=view&id=165.
8 Pathologies of Power: Health, Human Rights, and the New War on the Poor. With a foreword by Amartya Sen (University of California Press, 2003).
For a Model Curriculum on Ethics and Public Health developed by the Associated Schools of Public Health (ASPH), the Health Resources and Services Administration (HRSA), and The Hastings Center, go to: http://www.asph.org/document.cfm?page=723.
Public health professionals who wish next to examine contemporary issues from a legal as well as a moral perspective would do well to read Public Health Law and Ethics, edited by Lawrence O. Gostin (University of California Press, 2002), companion website available at: http://www.publichealthlaw.net/reader/. This collection of readings in public health law, ethics, and human rights provides a rigorous analysis of the philosophical, political, economic, and jurisprudential dimensions of government intervention to assure the health of the populace, and Professor Gostin provides a commentary on the meaning and importance of each selection.
For a timely analysis of moral and legal issues in American medicine and bioethics together with a plea for a more global rights-based perspective, see American Bioethics: Crossing Human Rights and Health Law Boundaries by George J. Annas
(New York: Oxford University Press, 2005).
The finest book I know for explaining the moral, legal, and practical significance of human rights to us and our nation is, In Our Own Best Interest: How Defending Human Rights Benefits Us All, by William F. Schulz, executive director of Amnesty International USA (Beacon Press, 2001).