The Role of Ethics in Shaping Public Health Policies

Imagine you are the public health director or head of the hospital in a small city where a deadly infectious disease has erupted. How would you allocate resources? Would you order a quarantine? Would you accept free resources from a pharmaceutical company? These are some of the myriad life-altering questions you might have to answer for yourself and your constituents as a public health leader.

Whether you're responding to a public health emergency, designing public health research, formulating health policy, or implementing public health interventions, your decisions as a public health practitioner can have far-reaching and sometimes unintended consequences. That's why the American Public Health Association (APHA) calls for ethics education to be included in core public health training and continuing education.¹

Learn more in this introduction to ethics in public health practice, including the essential ethical concerns, elements of an ethical framework and the relationship between public health ethics and medical ethics.

Public health ethics is a branch of applied ethics, which uses normative ethical principles to guide behavior in specific settings or roles. Normative ethics--the study of proper or moral behavior--were the subject of some of the earliest written records, as people living in society have always sought guidance on how to live together.

A good understanding of ethical frameworks can help public health officials and other professionals make decisions that more effectively meet the overarching goals of public health. In a training document for local health departments, the Centers for Disease Control and Prevention noted that ethical guidelines can help you navigate situations without consensus or clear legal guidance. Ethical frameworks can also help you allocate resources to accomplish the highest good, promote health equity and resolve conflicts between the needs of disparate parts of the community.²

Normative ethical systems are based on values, or our definitions of what is good or desirable. The 2002 and 2019 versions of the APHA Code of Ethics begin their guidance with discussions of public health values. The earlier document was created by the Public Health Leadership Society and adopted by the APHA. It affirms explicitly the organization's commitment to the 1948 Universal Declaration of Human Rights, asserting the universal right to a standard of living that supports health and well-being.³ The later document expands and recharacterizes the concepts of health and well-being as "flourishing" and explains:

"Flourishing occurs when capabilities for agency, creativity, intelligence, understanding, emotional engagement, and other positive human potentialities take shape in the form of lives well lived...The term human flourishing also underscores the relational interdependence among human beings, which is expressed in virtually all social and cultural activity and fits well with the contemporary understanding of the social determinants of health. The preconditions of everyone’s health are communal and systemic, and the field of public health must address them as such."¹

With that background, the Code enumerates six core ethical values and related obligations. The core values include:¹

• Professionalism and trust
• Health and safety
• Health justice and equity
• Interdependence and solidarity
• Human rights and civil liberties
• Inclusivity and engagement

Find more on the social determinants of health in The Global Impact of Public Health Policies on Health Equity. A core class in Kent State University's online MPH provides in-depth coverage of the social determinants of health behaviors, plus approaches to improving population health through interventions for behavioral health threats.

There are many similarities between the ethics frameworks for public health and clinical health practitioners and a few key differences. Public health agencies and health care organizations have a fiduciary relationship between the practitioner and the client. Ethical practice in both fields includes respect for justice, client autonomy and consent.

What distinguishes public health ethics from health care ethics is the scope of concern and a difference in focus on treatment or prevention. The ethics framework for clinicians is focused on treating individual patients and the fiduciary relationship between clinician and patient. In contrast, public health practitioners emphasize prevention and public stewardship, striving to support the greatest good for the whole community.²

Research is a vital component of public health and an area rife with ethical pitfalls. There are numerous historical examples of studies that have improperly conducted observational or biomedical research on human subjects, including children, incarcerated individuals and those who are mentally and physically diverse. The infamous Tuskegee syphilis study caused great harm through “gross ethical violations, including a lack of informed consent for participation, deception, withholding treatment, as well as racism and lack of scientific soundness.”⁴

The ensuing scandal led to the establishment of Institutional Review Boards (IRBs), which oversee research involving human participants. It also prompted the creation of the Belmont Principles, which include respect for persons, beneficence, and justice. These principles guide ethical research and the work of the IRBs by emphasizing the necessity of informed consent, the obligation to maximize benefits while minimizing harm, and the need to distribute the burdens and benefits of research fairly.⁵ The Belmont Principles are a cornerstone for ethical research and clinical practice.

Whatever the specific context, ethical public health practice is based on a multi-faceted balance of public and private health benefits. Whether you are practicing in the area of policy development, management of public health institutions or clinical research, the primary concerns that must be balanced are similar and include the following:

• Equitable healthcare access
• Allocation of scarce resources
• Informed consent and decision-making
• Privacy and confidentiality in health data
• Balancing civil liberties and public health

Noting that "identifying and cultivating ethical best practices is a reflective and dynamic endeavor," the APHA argues that professionals in health services and public health programs can avoid ethical issues by cultivating skills that guide them to values-based actions that are publicly defensible and morally appropriate. "Skill in ethical analysis and reasoning is an important competency for public health practitioners and decision-makers."¹

The COVID-19 pandemic brought the global scope of public health practice into sharp focus while highlighting differences in capabilities for public health intervention and approaches to health promotion among nations. The World Health Organization (WHO) noted, "Scholars and health care professionals have debated questions related to health and health care since the earliest days of medicine."⁶

An international organization of public health experts, the WHO works to coordinate "the world’s response to health emergencies, promote well-being, prevent disease and expand access to health care."⁷ As part of its work, the WHO published information on various topics, including ethics in health emergencies and disaster risk management, guidelines for public health surveillance, the use of artificial intelligence in public health, research ethics and other topics.

Recognizing the critical role ethics plays in public health policy and practice, Kent State University’s online Master of Public Health program integrates a rigorous Public Health Policy, Law, and Ethics course within its Health Policy and Management specialization. Valuable for all public health professionals, this course examines the intricate dance between ethics, law, and policy in the public health context. Students explore ethical theories and decision-making processes, learning how to apply them to real-world public health issues.

This course introduces students to the theories of ethical decision-making, set within the frame of the public health system and critical concepts of public health law and policy. By discussing ethical theories in the context of specific public health issues and examining legal authorities and public policy making, the course equips students to address complex ethical dilemmas. Graduates of this program emerge prepared to apply ethical principles to public health policy development and intervention strategies with sensitivity to the ethical considerations critical to achieving just and equitable health outcomes.

Kent State University's online Master of Public Health program is your pathway to a rewarding career at the forefront of global health solutions. Offering flexibility, a curriculum of excellence, and the opportunity to specialize in key areas of public health, this program is designed for professionals ready to advance their careers and tackle pressing health issues worldwide. With a focus on real-world applications and empowering courses like Public Health Policy, Law, and Ethics, you're set to make a significant difference.

Ready to transition into an impactful role within healthcare administration or policy-making? Schedule a call with an admissions outreach advisor today. Learn how the comprehensive 46-credit-hour program, with its blend of core courses, specializations, and electives, can be tailored to align with your career goals and passions, empowering you to lead with confidence and expertise.