2. Childress et al. Thesis
Ethical issues in public health should be resolved
by thinking through how to apply general moral
considerations and paradigm cases to those
issues.
3. What is Public Health?
Public health focuses on the health of an entire population.
Its goal is to promote health and prevent disease and disability in a
population.
Differs from medicine, which focuses on the health of individual patients.
What does “public” mean?
Childress et al. give three meanings:
1. Numerical Public – a target population
2. Political Public – us acting through government and public agencies
3. Communal Public – us acting through social and community organizations,
including private organizations
4. Public Health Ethics
Just as ethical issues arise in medicine, ethical issues also arise in
public heath.
Examples:
Should we have mandatory screening of pregnant women for HIV?
Should the government require people to shelter in place
during the coronavirus pandemic, and if so, for how long?
5. How to Do Public Health Ethics
General Moral Considerations: Think about how general moral considerations
apply to a particular ethical issue in public health.
Example: Consider how respect for autonomy bears on the issue of requiring people to
shelter in place during the coronavirus pandemic.
Conflicts may occur: different general moral considerations may favor different ethical
conclusions about a particular issue.
Casuistical Reasoning: Consider how paradigm cases or precedent cases are
similar to or different from a particular ethical issue in public health.
Example: In determining whether to require screening for HIV, look to cases in which
screening was done for other infectious diseases.
6. General Moral Considerations
The general moral considerations relevant to public health ethics include:
• Producing benefits
• Preventing harms
• Utility – maximizing the good
• Fair distribution of benefits and harms
• Respecting autonomy
• Protecting privacy and confidentiality
• Promise-keeping
• Transparency
• Building and maintaining trust
7. These general moral principles provide prima facie reasons in support of
actions.
Recall: a prima facie reason is a reason that might be outweighed by other
reasons.
Hence, if a public health invention might substantially increase life-expectancy,
then that is a prima facie reason to do that invention.
But that reason might be outweighed by, say, the fact that the
intervention fails to respect autonomy.
Example: Making annual wellness check-ups mandatory.
8. Resolving Conflicts Among
General Moral Considerations
Focus on cases in which a public health intervention would bring benefits,
avoid harms, and maximize utility but would infringe on individual liberty
or justice.
Should the intervention be done?
Childress et al. propose 5 “justificatory conditions” to help determine if the
intervention should be done.
9. 5 Justificatory Conditions
1. Effectiveness: The intervention must be effective at promoting public health.
2. Proportionality: The prima facie reasons favoring the intervention must outweigh
the prima facie reasons against the intervention.
3. Necessity: The intervention must be necessary to achieve the public health goal.
There must be no alternative that is less morally troubling.
4. Least Infringement: The intervention must minimize the infringement on individual
liberty or justice.
5. Public Justification: The intervention must be explained and justified to the
relevant parties whenever possible.
10. Example: Screening
Pregnant Women for HIV
Policy Proposal: Mandatory screening of pregnant women for HIV, especially those
deemed “high risk” for HIV, before a treatment was available.
This proposal didn’t satisfy any of the justificatory conditions.
Policy Proposal: Same proposal after AZT to prevent perinatal transmission of HIV
was available.
Effectiveness supported this proposal. It would work.
But not clear that proportionality/necessity supported it over voluntary screening
because of the infringement on liberty, privacy and justice. Better not to use coercion
if possible.
Better solution: Voluntary screening that encourages screening.
11. Example: Scarce
Medical Resources
What should doctors do about a shortage of ventilators during the COVID-19
pandemic?
Conflict:
Utility (maximizing the good) supports giving the ventilators to those most likely to survive.
Respect for autonomy supports acting in a particular patient’s best interest. It may seem to
require giving everyone an equal chance at a ventilator, such as with a lottery system, or
prioritizing those who are sickest or who arrive first. Fair distribution of benefits and harms
may also support this.
Here it seems clear that considerations of utility win out. Giving ventilators to those
most likely to survive is effective and proportional. It can be publicly justified. It just
needs to be done in a necessary way, with least infringement.
12. Public Accountability
Public accountability in public health involves:
Public justification
Soliciting input from relevant sources
Transparency in seeking and disclosing information
Public accountability is crucial because it provides a basis
for public trust.
13. Public Health and Paternalism
(Recall) PATERNALISM: limiting a person’s autonomy to prevent harm
to that person or others.
Paternalistic public health interventions are public health
interventions in response to agents’ actions that are “self-regarding”
and either nonvoluntary (weak paternalism) or voluntary (strong
paternalism).
Self-regarding actions = the bad effects fall primarily on the agent herself
Strong paternalism is typically thought to be morally wrong
14. Public Health and Paternalism
Childress et al. point: It can be difficult to know if a public health intervention is
paternalistic or, if it is, whether it is weak or strong paternalism.
Example: Does the effect of food marketing on diet make people’s dietary
choices nonvoluntary?
If so, intervening would just be weak paternalism. If not, it would be strong
paternalism.
Example: Should motorcyclists be legally required to wear helmets?
Would this intervention be paternalistic? It depends upon whether motorcyclists’ failing
to wear helmets is self-regarding.
What about the financial and emotional costs to others of their failing to wear helmets?
15. Public Health and Paternalism
Is the shelter-in-place law in response to the coronavirus
pandemic paternalistic?
Plausibly, no.
Going out in public is plausibly an “other-regarding” action in
the sense that the bad effects commonly fall primarily on
others.
16. Don’t exaggerate the conflicts in public health ethics.
Normally, “the most effective ways to protect public health respect general
moral considerations rather than violate them.” (p. 797)
• Promoting public health, protecting human rights, and promoting
other values like autonomy are often “mutually supportive.” (p. 797)
