Elsevier

The Lancet

Volume 359, Issue 9311, 23 March 2002, Pages 1055-1059
The Lancet

Department of Ethics
Ethical analysis in public health

https://doi.org/10.1016/S0140-6736(02)08097-2Get rights and content

Summary

Public-health regularly encounters serious ethical dilemmas, such as rationing scarce resources, influencing individuals to change their behaviour, and limiting freedom to diminish disease transmission. Yet unlike medical ethics, there is no agreed-upon framework for analysing these difficulties. We offer such a framework. It distinguishes three philosophical views, often invoked in public-health discourse: positions based on outcomes (utilitarianism), positions focused on rights and opportunities (liberalism), and views that emphasise character and virtue (communitarianism). We explore critical variations within each approach, and identify practical problems that arise in addressing the ethical dimensions of health policy. We conclude by examining challenges posed by the feminist argument of ethics-of-care and by postmodern views about the nature of ethics. Health professionals need enhanced skills in applied philosophy to improve the coherence, transparency, and quality of public deliberations over ethical issues inherent in health policy.

Introduction

Public-health decisions commonly involve conflicting and ambiguous ethical principles. Ideas like efficiency, human rights, cultural respect, equity, and individual choice are commonly invoked but rarely analysed in public-health debates. Yet how these concepts are understood and used can lead to quite different policies. How is cultural respect to be reconciled with human rights when local elders reject equal access to education for females? Is a tax on wages an equitable way to finance health care? What does so-called individual choice mean for an addicted substance user who both wants and does not want to transform her own life experience?

Medical ethics, focused on doctor/patient relationships, is widely discussed and taught to medical students.1 But a comparable field of public-health ethics is not as well developed to guide public-health practitioners.2 We seek to fill that gap by providing a method for describing and analysing the major ethical ideas invoked in discussions of public-health policy.

Our approach sorts ethical arguments into three major categories, each representing a major theme in contemporary public-health discourse: utilitarianism, which asserts that decisions should be judged by their consequences, in particular by their effect on the sum total of individual well being; liberalism, which is focused on rights and opportunities, on where people start, not on where they end up; and communitarianism, which involves visions of an appropriate social order and the virtues that will maintain such an order in a particular community. We also discuss a challenge to this framework raised by recent writings of the ethics-of-care school of feminism.

Section snippets

Consequences

Public-health policymaking is often based on an analysis of consequences. The right choice is viewed as the one that produces the most gain, for example, the largest reduction in the burden of disease. For public-health professionals, this perspective has a strong intuitive appeal.

Philosophically, a leading exponent of this argument was Jeremy Bentham (1748–1832). Bentham proposed a particular way to measure consequences, namely, by the impact of decisions on the wellbeing of all affected

Rights

In recent years, public-health professionals have become increasingly interested in the idea of rights. However, the nature and definition of such rights are often controversial.13 From a public-health perspective, are there rights to health itself or to health care? Whose rights take precedence, those of a mother or those of an unborn fetus, and under which conditions? How do health rights relate to human rights more generally? Indeed, some countries have strongly disputed the imposition of

Communities

A focus in ethics on creating a good society, and on producing the right individuals for that society, has a long history. Such communitarian viewpoints are found among Greek philosophers (Plato and Aristotle), among many religious figures, and in many non-western traditions such as Neo-Confucianism.

Communitarianism includes a wider set of substantive philosophical positions than liberalism and utilitarianism, since there are many different views about what constitutes individual and social

The problem of justification

Confronted with these three basic ethical positions, one might well ask which is correct? What arguments are available to select one ethical view over another? Such questions about justification fall into the realm of meta-ethics, or questions about the nature of ethics itself.

There are various ways of justifying an ethical position. Religious faith is one. Another is the view that human beings have a special faculty for perceiving morality, so that moral truth is revealed to us by our emotions

A feminist challenge

In recent years, a provocative challenge to the arguments presented above has emerged from feminist thinkers, a challenge we believe is of particular relevance to public health. As a social movement, feminism has relied on various ethical ideas, including both utilitarianism and liberal rights-based arguments. However, one newer argument, worthy of particular attention, is called ethics-of-care feminism. A form of consequentialism, ethics-of-care focuses on outcomes, but in a way that

Conclusion

Public health today grapples with issues rife with ethical dilemmas and political conflict: from toxic wastes and AIDS, to health-care costs and so-called mad cow disease. Yet public-health professionals have minimal training in ethical analysis. If health professionals are to develop coherent positions on these issues, and contribute to democratic deliberation about public policies, then they need enhanced skills in applied philosophy. Understanding alternative ethical arguments has become as

References (41)

  • S Anand et al.

    Disability-adjusted life years: a critical review

    J Health Econ

    (1997)
  • TL Beauchamp et al.

    Principles of Biomedical Ethics

    (1994)
  • SS Coughlin et al.

    Ethics instruction at schools of public health in the United States

    Am J Public Health

    (1999)
  • J Bentham

    The Principles of morals and legislation

    (1996)
  • PS Wenz

    CBA, utilitarianism and reliance upon intuitions

  • J Griffin

    Well Being

    (1986)
  • H Margolis

    Dealing with risk: why the public and the experts disagree on environmental issues

    (1996)
  • R Rosser et al.

    Index of health-related quality of life

  • C Taylor

    The diversity of goods

  • T Nagel

    War and massacre

  • EJ Perez-Stable

    Cuba's response to the HIV epidemic

    Am J Public Health

    (1991)
  • SG Stolberg

    Health Secretary urges donor priority for sickest patients

    (Feb 27, 1998)
  • R Dworkin

    Justice in the distribution of health care

    McGill Law Journal

    (1993)
  • P Shenon

    US to propose new criticism of rights in China

    (Jan 12, 2000)
  • I Kant
  • O O'Neill

    Constructions of reason

    (1989)
  • T Scanlon

    Value desire and quality of life

  • J Rawls

    Political liberalism

    (1993)
  • R Nozick

    Anarchy, state and utopia

    (1974)
  • N Daniels

    Just health care

    (1985)
  • Cited by (180)

    • Allocating scarce intensive care resources during the COVID-19 pandemic: practical challenges to theoretical frameworks

      2021, The Lancet Respiratory Medicine
      Citation Excerpt :

      Finally, ICU clinicians are crucial members of triage committees, but they were also some of the very resources in scarcity, indispensable for bedside patient care, seriously limiting their availability to participate in such committees, a point also highlighted by others.25 Decision making based on an analysis of outcomes requires reasonably sound and valid prediction based on the specific context.26 For COVID-19, the knowledge to assess the outcome of different therapeutic options is still limited and, in many areas, not sufficiently accurate due to lack of definitive data.27

    • Pediatric Mass Casualty Preparedness

      2020, Anesthesiology Clinics
    View all citing articles on Scopus
    View full text