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5 Public Health Ethics, Law, and Policy

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Learning Outcomes

After reading this chapter, you should be able to

• Explain the relationship between ethics and public health work.

• List the central assumptions of the Public Health Code of Ethics.

• Summarize the importance of key public health cases.

• Illustrate how policies and laws are utilized in public health efforts.

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Section 5.1 The Role of Ethics in Public Health

The ethics, morals, laws, policies, and legislation involved in public health can become very confusing, even for those who work in the field. This chapter provides a brief overview of each of these elements, plus examples of their importance and function in the public health realm. In public health, it is important to understand and differentiate between terms such as ethics and morals, as they can be vastly different in practice. The Public Health Leadership Society’s principles of ethical practice are also key to understanding how and why public health offi- cials make policy recommendations.

Lastly, this chapter discusses the difference between policy and law, focusing on how policy shapes public health, including its responsibilities and its outcomes. The role of policy briefs, their purpose, and how they are written is explored, and examples of existing policies that became laws and how they have worked within the public health realm are summarized.

5.1 The Role of Ethics in Public Health Morals and ethics are very much alike in many respects, and the terms are often used inter- changeably; however, they are not the same concepts. Morals are an individual’s principles of right and wrong. They set the stage for acceptable behaviors and beliefs. Morals are not uni- versal, and they are highly individualized, often shaped by upbringing and culture. A person living in House A on Street A may believe that elbows on the table during dinner is unaccept- able (it is “wrong,” or immoral), while a person living in House B on Street B may believe that elbows on the table at meal time is fine (it is “right,” or moral).

Ethics are principles that govern a person’s behavior because they are rules provided by an external source, such as codes of conduct in a community setting or a workplace. Ethics are more universal and common to a set community. For example, the community of residents on Street B are Amish, and those on Street A are not Amish. The community ethical code in the Amish community (everyone on Street B) would state that elbows on the table are unethical behaviors. This is now considered a principle governed by an external source (the Amish community). So, while the person living in House B on Street B may have a moral belief that elbows on the table are fine, the community of Street B says it is unethical. This is where ethics and morals can collide. In most situ- ations, the ethics of the community outweigh the morals of the individual.

In public health, morals and ethics collide fre- quently in decision-making. Vaccinations against certain diseases are good examples of this colli- sion. For instance, the state of Pennsylvania might represent the community and mandate vaccination. In this case, Pennsylvania is the external source that sets the code of conduct—the ethical standards for those who live in the state. But there may be many individuals in the state who personally disagree with this code and refuse vaccination. The individuals’ moral beliefs collide with the overarching community’s code.

Ridofranz/iStock/Thinkstock Personal and cultural beliefs about allowing terminally ill or dying patients to refuse treatment or request physician-assisted suicide may conflict with laws.

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Section 5.1 The Role of Ethics in Public Health

Who wins? Who is right? If the law intervenes, it will usually be the community ethical stan- dards that will be upheld; however, if there are no laws, the individual’s morals may stand.

A national law states that all children must receive vaccinations before attending school. In this case, if an individual is opposed to vaccination yet has a child who needs to attend school, the individual must abide by the law in order to send the child to school.

As noted in the vaccination example, laws do not always agree with every single community’s morals, but the laws are established to protect that society as a whole. In many cases, laws truly conflict with ethics and morals. For example, it is illegal to kill another human being, even in cases of physician-assisted suicide for dying, or terminal, patients. However, some cultures and individuals believe that it is ethical to allow a person to die with dignity rather than live in pain. Individually, people may believe that physician-assisted suicide is also right. In this case, ethics and morals are similar, but the law prohibits the intended action.

Research and Clinical Ethics The idea that ethics plays a role in public health is relatively new. More widely understood are the concepts of research ethics and clinical ethics. Research ethics involves the protections of human subjects who are taking part in a study. This usually includes a plethora of disclo- sures and permissions. Most people won’t encounter the concept of research ethics unless they are part of a research project.

Clinical ethics is more commonly understood because it is encountered in doctor’s offices, clinics, hospitals, and all health-related organizations and facilities. Clinical ethics addresses issues that arise within the patient care realm. Privacy and confidentiality of the patient are the most common ethical practices in the clinical setting, the importance of which contrib- uted to the law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This law requires the protection and safeguarding of all personal health information. Ethically, it seems obvious that health information should be private, and many offices had already been keeping it private before the law was passed because it was valued as important. Making it law transformed this ethical practice into a legal requirement.

Public health is quite different from clinical health, and, therefore, the focus areas of ethics in both arenas are different. Clinical ethics is related to the treatment of disease and injury, while public health ethics is important in the prevention of disease and injury. Table 5.1 shows a comparison of the two.

The terms principles and values appear frequently in this chapter, and both play a key role in the ethical practice of public health. However, whose principles and values are being consid- ered? While all people have values of some sort, public health values are rooted in science and community in an effort to prevent disease and injury, protect the public from harm, and pro- mote health and well-being (Barrett et al., 2016). Public health professionals do not use their morals when making decisions that will affect the public. Public health values rest on two ideas: that most health interventions rely upon the community’s acceptance, cooperation, and participation to be successful, and that public health must gain a community’s trust to be able to function effectively. These are the guiding values of public health and the basis for all actions that public health professionals perform at the local, state, federal, and global levels.

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Ethics and Public Health Decision-Making In all public health activities, principles and values provide the framework and justification for decision-making. In essence, every aspect of public health must adhere to an ethical frame- work. The CDC (2017w) follows three core functions when applying an ethical framework to its activities:

1. Identify and clarify the ethical dilemma. 2. Analyze the dilemma in terms of alternative courses of actions plus whatever result-

ing consequences may occur. 3. Resolve the dilemma through decision-making that incorporates and balances the

guiding principles and values.

This framework comes with several key questions to help public health professionals walk through the process to determine the next steps.

Core Function 1: Identifying and Clarifying the Ethical Dilemma When examining a potential intervention in public health, the first step is to provide the foun- dation on which to base the decision. These questions are usually discussed at length:

• What are the risks, harms, and/or concerns? • What are the public health goals? • What is the scope of legal authority? That is, what laws and regulations may or may

not apply?

Table 5.1: Comparison between clinical and public health ethics

Clinical ethics Public health ethics

Medical interventions by clinical professionals Range of interventions by various professionals

Individual benefit Social, community, or population benefit

Seeks to avoid harm based on the provider’s fiduciary relation to the patient

Seeks to avoid harm based on collective action

Respect for individual patients Relational autonomy of interdependent citizens (community)

Professional duty for patients over provider Duty to community over individual

Based on trustworthiness of physician and medical profession

Based on law

Informed consent from individual Community consent through consensus

Limited to treating patients equally and ensuring universal access to health care

Concern with social justice regarding health and achieving health equity

Source: Adapted from “Public Health Ethics: Global Cases, Practice, and Context,” by L. W. Ortmann, D. H. Barrett, C. Saenz, R. G. Bernheim, A. Dawson, J. A. Valentine, and A. Reis, in D. H. Barrett, L. W. Ortmann, A. Dawson, C. Saenz, A. Reis, and G. Bolan (Eds.), Public Health Ethics: Cases Spanning the Globe (Vol. 3, p. 23), 2016, Geneva, Switzerland: Springer International Publishing, Open Access.

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Section 5.1 The Role of Ethics in Public Health

• What are the moral norms of the community? • Are there any similar cases that provide legal or ethical guidance?

Consider the potential issues of requiring motorcyclists to wear helmets. In this situation, public health officials have to analyze the risks to, and concerns of, the rider as well as those who may be affected, such as the rider’s family, those who pay for the medical services and costs, and other people on the road. The ethical dilemma is “What harm would come if hel- mets were required for all motorcyclists?”

This function of the framework also examines community norms. Is there a social concern with motorcyclists not wearing helmets across the state? Is there a strong advocacy call for helmet use? What economic issues would result if helmets were required? Obviously, there is the cost of the helmet, but there is also the cost of medical care in the event an accident occurs. Some people in opposition to the helmet laws state that it violates their personal rights to make their own choices. Supporters of the laws claim that those who get into acci- dents and succumb to head trauma drain medical resources—especially those who do not have insurance. It is an injury that can be prevented just by wearing a helmet.

States’ opinions on the helmet law vary based on the answers to these questions. Some have no laws or require only passengers under age 17 to wear a helmet; others require everyone on a motorcycle to wear one (Insurance Institute for Highway Safety, 2018). The state of New York requires the use of helmets and has since 1967 (Insurance Institute for Highway Safety, 2018). Refer to A Closer Look for another example of a state examining an ethical dilemma in public health.

A Closer Look: Applying the Ethical Framework to Alaska Smoking Laws

While Alaska has one of the most lenient smoking laws in the United States, smoking is prohibited in schools, childcare facilities, most health care facilities, and elevators (American Lung Association, 2016). However, the state government has left the door open for communities to take matters into their own hands, which includes establishing stricter regulations if they wish to do so.

While public health professionals view the ban as a lifesaving measure, others see it as an attack on personal rights. This is an ethical dilemma that the state cautiously addressed by leaving the main decisions in the hands of each municipality. The state law takes into consideration the rights of smokers by not banning the practice under one law.

(continued)

Stefan Malloch/iStock/Thinkstock Alaska has one of the most lenient smoking laws in the United States. Communities can apply stricter regulations if they wish to but are not required to do so.

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Section 5.1 The Role of Ethics in Public Health

Core Function 2: Analyzing the Dilemma This function revolves around options. Three key points are considered:

• What are the short- and long-term options given the responses to the questions from Core Function 1?

• What are the ethical concerns of each option? • Are there other considerations that should be reviewed, such as privacy, commit-

ments, or transparency?

One such public health dilemma received considerable attention and review at this step of the ethical framework: bicycle helmet usage. In the early 1970s, the issue gained momen- tum in Australia, where a significant number of bicyclists died from head injuries. The Royal Australian College of Surgeons actively campaigned to raise awareness of head injuries and their prevention through the use of helmets. Shortly after the campaign went into effect, Aus- tralia became the first country to require helmets for bicyclists, in the early 1990s (Rachele,

A Closer Look: Applying the Ethical Framework to Alaska Smoking Laws (continued)

The compromise was simple: If a community desires to allow smoking, it must designate specific locations and clearly mark them with signage. This is to protect the health of those who do not wish to inhale secondhand smoke, as the law states that everyone has the right to clean air. The signage is helpful, but some municipalities did desire to go beyond the state’s law. As a result, some major cities and smaller towns adopted stronger policies based on residents’ desires (see Core Function 1 of the ethical decision-making framework):

• Sitka, November 18, 2005: Banned smoking in all enclosed workplaces, including restaurants but exempting bars

• Anchorage, July 1, 2007: Banned smoking in all workplaces, bars, and restaurants • Juneau, January 2, 2008: Banned smoking in bars and restaurants (but not other

workplaces) • Nome, September 20, 2011: Banned smoking in bars, restaurants, outdoor stadiums,

vehicles when used for public transportation, and all enclosed workplaces

Only 11 cities in the state of Alaska have adopted completely smoke-free workplaces: Anchorage, Bethel, Haines, Juneau, Klawock, Nome, Palmer, Petersburg, Skagway, Unalaska, and Valdez. Most of the cities and towns in Alaska abide by the signage law imposed by the state.

Sources: American Lung Association. (2016). SLATI state information: Alaska. Retrieved from http://www.lungusa2.org/slati /statedetail.php?stateId=02 State of Alaska. (2017). Alaska smoking law. Retrieved from http://dec.alaska.gov/eh/fss/Smoking_Home.html

http://www.lungusa2.org/slati/statedetail.php?stateId=02

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Section 5.1 The Role of Ethics in Public Health

Badland, & Rissel, 2017). New Zealand followed suit in 1994. Deaths and head injuries from bicycle riding began to drop due to helmet use, and the word was spreading into other coun- tries. In 1987, the United States began to adopt helmet laws at the state level; however, there was pushback from adults (Helmets.org, 2017). Most people agree that protecting children under age 18 is important. Therefore, laws that focused on children and youth helmet use were mostly welcomed.

Today in the United States, there are no federal laws requiring bicycle helmet use by anyone riding a bicy- cle. Twenty-two states require helmet use, typically for children, and more than 200 localities (munici- palities, cities, etc.) maintain local ordinances on the issue (Helmets.org, 2017). For example, Kansas does not have a statewide law requiring helmet use while riding a bicycle, but the city of Lawrence, Kan- sas, requires all children and youth under age 16 to be helmeted (Helmets.org, 2017). There is no law in any state that requires adults to wear a helmet (Insurance Institute for Highway Safety, 2017b). According to Nicaj et al. (2006), 97% of bicyclists who died in an accident in New York City from 1996 to 2005 were not wearing a helmet.

Bicycle helmet use remains a significant ethical dilemma for communities. When addressing the questions in Core Function 2, the local municipali- ties were given the authority to determine whether a bicycle helmet law would invade their residents’ rights, privacy, and way of life. Public health lost the battle to have an overarching law on helmet use, as regulations more often focus on the protection of children rather than the entire population of bicycle riders. Advocacy groups are still working toward a federal law requiring all bicyclists to don a helmet.

Core Function 3: Resolving and Justifying the Decision Decisions in the public health realm are not random. They require solid justification by taking into consideration all aspects and opposition. Public health officials ask five key questions when justifying decisions (Table 5.2). One important aspect related to the practice of public health is to ensure that the values of the community do not clash with the values of the public health intervention. After all steps are reviewed and options considered, the decision mak- ers must be able to address the five factors and their associated questions in full to adopt an intervention, law, or policy.

LydiaGoolia/iStock/Thinkstock There are no federal laws that require helmet use for anyone riding a bicycle, but about half of the states have laws that require helmet use, typically for children.

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Section 5.1 The Role of Ethics in Public Health

For example, not all states have adopted helmet laws for motorcyclists because those five key elements could not fully address all residents’ questions. The biggest element fell under “least infringement,” where people felt this law was a violation of their values, rights, and principles. The intervention was intended to increase safety, but it collided with the values of motorcycle riders themselves. As a result, only 19 states and the District of Columbia have laws requiring motorcyclists to wear helmets (Insurance Institute for Highway Safety, 2017a). In addition, 28 states have modified laws, requiring only some motorcyclists to wear helmets. Three states have no law at all: Iowa, Illinois, and New Hampshire (Figure 5.1).

Table 5.2: Justification for public health decisions

Factor Key questions

Effectiveness Is the action going to be effective? Will it make a difference in terms of the overall goal(s)?

Proportionality Will the benefits outweigh the infringement on the community’s individual values, principles, and morals?

Necessity Is this intervention truly needed to achieve the goal(s)?

Least infringement Will this intervention cause the least disruption and upheaval of the community’s values, principles, and morals?

Public justification Is there solid evidence to justify this decision that most people will find acceptable?

Source: Adapted from “Public Health Ethics: Global Cases, Practice, and Context,” by L. W. Ortmann, D. H. Barrett, C. Saenz, R. G. Bernheim, A. Dawson, J. A. Valentine, and A. Reis, in D. H. Barrett, L. W. Ortmann, A. Dawson, C. Saenz, A. Reis, and G. Bolan (Eds.), Public Health Ethics: Cases Spanning the Globe (Vol. 3, p. 29), 2016, Geneva, Switzerland: Springer International Publishing, Open Access.

Figure 5.1: Motorcycle helmet laws by state

Most states have some type of law regarding motorcycle helmet use. Only three states have no law requiring the use of a helmet while riding a motorcycle: Iowa, Illinois, and New Hampshire.

Source: Insurance Institute for Highway Safety, Arlington, Virginia USA. http://www.iihs.org. Used with permission.

AZ NM OK

KSCO

WI MN

IL IA

LA MS AL GA

NC TN

IN OH PA

WVVA

MA NH

DE NJ CT

MD DC

MEVT

Universal law Partial law No law

http://www.iihs.org

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Section 5.2 The Public Health Code of Ethics

In 2015 alone, helmets saved the lives of 1,772 people. If every motorcyclist had worn a hel- met when riding, another 740 more could have been saved (CDC, 2017o). Helmets reduce the risk of death by 37% and the risk of head injury by 69% (CDC, 2017o). Furthermore, accord- ing to the CDC (2017o), helmet use would save more than $1 billion.

However, it is important to note that people in a community are far more committed to their political views, ethical and religious values, and how a specific law, policy, or action might affect them personally than to scientific evidence or community impact. That is why not all states have enacted a full universal law making helmets a requirement when riding a motorcycle.

This policy has been far more controversial than any other traffic law on record. In 1967, the federal government enacted a helmet law, which prompted the establishment of motorcycle rights groups (Homer & French, 2009). The federal helmet law was revoked in 1976. Some of these groups still encourage motorcyclists not to wear helmets and argue that effective rider training and education sessions, not legally required helmet use, will result in fewer accidents and fatalities (Homer & French, 2009). Public health professionals continue to work through the steps in communities and states separately, hoping for improved results to eventually enact a federal law requiring helmet use.

5.2 The Public Health Code of Ethics Those in public health have an obligation to protect the health of the public. This obligation has a strong moral basis and involves a significant amount of trust. This is why a code of ethics is important. A code of ethics represents a professional’s commitment to honor the public’s trust and to avoid abusing power in a way that deprives a population or community of posi- tive outcomes. While public health practice has existed for centuries (as noted in Chapter 1), a universal code of ethics did not emerge until 2002.

Origins and Development The code originated as a class project of the 2000 graduating class from the Public Health Lead- ership Institute (Thomas, Sage, Dillenberg, & Guillory, 2002). The institute provides advanced leadership training to those already in public health professions. The 2000 graduating class had members from various agencies, including the CDC; American Public Health Association (APHA); National Association of City and County Health Officers (NACCHO); departments of health in Connecticut, Ohio, Maine, Virginia, and Alabama; and Center for Health Leadership and Practice in Oakland, California (Thomas et al., 2002).

The code focuses on those who work in public health, including public health departments, schools of public health, and institutions with a public health focus. It took 2 full years of devel- opment to finalize the document, which included values and belief statements, explanations, and 12 specific ethical principles (see Table 5.3). The APHA Executive Board formally adopted the code on February 26, 2002. The APHA is a membership-based organization focused on improving the health of communities across the United States and beyond. The group advo- cates for and has influenced many public health policies supported by scientific research and brings together members from all fields of public health. Not long after the APHA adopted the

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Section 5.2 The Public Health Code of Ethics

code, further adoptions came from the CDC, NACCHO, the Association of State and Territorial Health Officials, the Association of Schools of Public Health, and a plethora of other public health organizations. Once the code is adopted, an organization must then integrate the prin- ciples into all of its policies, procedures, and actions.

Key Assumptions The code of ethics is a document called Principles of the Ethical Practice of Public Health. It is widely used as the foundation for ethical practice in public health. The preamble to the code explains its purpose and audience:

The code is neither a new nor exhaustive system of health ethics. Rather it highlights the ethical principles that follow from the distinctive characteristics of public health. A key belief worth highlighting, and which underlies several of the Ethical Principles, is the interdependence of people. This interdependence is the essence of community. Public health not only seeks to assure the health of whole communities but also recognizes that the health of individuals is tied to their life in the community. (Public Health Leadership Society, 2002, p. 4)

This code is intended for public health professionals and other institutions that focus on pub- lic health initiatives to provide the least harm for the greatest good in all public health–related actions. Those who adopt this code must also understand the underlying values and beliefs that the Leadership Society calls “key assumptions” for all professionals. These assumptions fall within three areas: health, community, and bases for action.

Health The key assumption for this area is that every human being has a right to health resources. The code affirms the first notation under Article 25 of the Universal Declaration of Human Rights, which states that all people have a right to a standard of living for positive health and well-being:

Everyone has the right to a standard of living adequate for the health and well- being of himself and of his family, including food, clothing, housing and medi- cal care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of liveli- hood in circumstances beyond his control. (United Nations, 1948, article 25, section 1)

Community There are six assumptions under this value:

1. All humans are interdependent, meaning that we require companionship, friendship, family, and social interaction for survival. Positive relationships, especially among institutions, make up the basis for a healthy community. Under this assumption, it is noted that one person’s decision can affect other people.

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Section 5.2 The Public Health Code of Ethics

2. Without the value of trust, a community cannot be effective in any public work. There must be trust between the pub- lic and public health institutions, and this includes truth telling, transparency, accountability, reliability, and reciprocity.

3. People do not work in silos. To accomplish positive outcomes in health, a community must collaborate and work together as one unit.

4. Humans interact with their environments; therefore, a healthy environment makes for a healthy community. In other words, poorly designed communities or poor man- agement of natural resources can generate unhealthy populations.

5. People in a community must be able to speak out against or for an action and feel that their voices are heard. This assumption requires a process for community mem- bers to develop and evaluate policy and actions before they are implemented.

6. Public health professionals cannot come into a community and change whatever they want if the community is not on board with said change. This is where solid assess- ment can ensure the community identifies its fundamental needs. This assumption works hand in hand with the third assumption of collaboration: People must learn to work together to promote a community’s health needs.

Bases for Action This area comprises four specific assumptions: knowledge, science, responsibility, and action.

1. Knowledge revolves around ensuring that people of a community have the informa- tion they need to make decisions about their community’s health. This could involve participation in policy-making or engaging community members via promotion and education campaigns.

2. Science becomes the basis for all decisions made in the public health realm. Scien- tific tools used include qualitative and quantitative methodologies to assess and evaluate a population’s needs. These activities become critical evidence that is used to develop interventions for health improvement.

3. Responsibility means that community members are given the role of making deci- sions based on science and knowledge. Failure of community members to act in any manner breaks this assumption and indicates an unwillingness of a community to move toward healthier outcomes. Without this assumption, it is difficult for any movement toward improvements to be effective.

4. Actions are often performed without full information simply because it is unavailable or unknown. The values and beliefs statements in the code note that action is often required in the absence of full information on a topic. It is important to know that the values and dignity of each person in a community are often the driving force behind actions, more so than science-based evidence and research. Whichever is followed, a community must do so with full consensus and collaboration.

dolgachov/iStock/Thinkstock Humans have an interdependent relationship with the environment. Thus, the design of a community and the management of its natural resources affect the population.

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Section 5.2 The Public Health Code of Ethics

Principles of Ethical Practice Taking these value and belief assumptions into consideration, these principles of practice are followed by all public health professionals in the United States (Table 5.3).

Table 5.3: Principles of the ethical practice of public health

1. Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.

2. Public health should achieve community health in a way that respects the rights of individuals in the community.

3. Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members.

4. Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all.

5. Public health should seek the information needed to implement effective policies and programs that protect and promote health.

6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation.

7. Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public.

8. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community.

9. Public health programs and policies should be implemented in a manner that most enhances the physical and social environment.

10. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others.

11. Public health institutions should ensure the professional competence of their employees.

12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.

Source: From “Principles of the Ethical Practice of Public Health” (version 2.2), by Public Health Leadership Society, 2002 (https://www.apha.org/-/media/files/pdf/membergroups/ethics/ethics_brochure.ashx).

Every action performed by public health professionals must occur under an ethical code. The code should guide practitioners in how they tackle a health problem. Section 5.3 includes three cases that ended up in court and that highlight the importance of having an ethical code.

https://www.apha.org/-/media/files/pdf/membergroups/ethics/ethics_brochure.ashx

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Section 5.3 Public Health Ethics Cases

5.3 Public Health Ethics Cases For many public health lawsuits, the courts are asked to weigh the rights of the individual against the responsibilities and rights of a larger organization, such as the federal or state government. When does a person’s right to decide for himself or herself trump a public health concern, and vice versa? For example, in 1885, the Supreme Court ruled that some actions are essential for the health of the population even if they restrain individual liberties (Barrett et al., 2016). While courts are primarily concerned with the law, legal debates often become ethical debates as well. The following three cases illustrate how having a public health code of ethics can help clarify what decisions need to be made.

Case No. 1: Jacobson v. Massachusetts Jacobson v. Massachusetts (1905) is considered the most important public health case to support states’ rights when creating and enforcing laws that limit individual autonomy in favor of protecting public health (Barrett et al., 2016; Gostin, 2008).

In the early 1900s, the state of Massachusetts man- dated vaccination against smallpox. Anyone who did not receive the vaccination was fined $5. Cam- bridge minister Henning Jacobson refused the vac- cine and also refused to pay the fine. His first argu- ment was that he had once received the vaccine as a child in Sweden and experienced a long period of suffering following the inoculation (Barrett et al., 2016). His second argument stated that the law was hostile and removed personal freedom of choice for individuals. Both state and superior courts ruled against Jacobson, stating that there were no exemptions permitted and that medical history had no bearing on his ability to refuse the vaccine. However, one of the key findings from the State Supreme Court was that if people refused to be vaccinated, it was not within the power of the public health realm to force inoculation (Commonwealth v. Henning Jacobson, 1903).

This case eventually went to the U.S. Supreme Court, where it was determined that anyone with a health condition should not be subject to the vaccination, as it would be considered “cruel and inhuman in the last degree” (Barrett et al., 2016, p. 42). The court then found Jacobson to be in perfect health, which required him to receive the vaccination. The final rul- ing was for Jacobson to either obtain the inoculation or pay the fine. He eventually paid the $5 fine as outlined by the law (Barrett et al., 2016).

This case illustrates the potential conflict between a community’s health and well-being and personal rights and freedoms. When a personal right puts the rest of the community at risk, then that personal right is an infringement on the population’s well-being. In this case, even the U.S. Supreme Court felt the public’s health trumped individual rights.

scyther5/iStock/Thinkstock Do laws that require citizens to receive certain vaccinations to promote overall public health infringe upon personal rights?

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Section 5.3 Public Health Ethics Cases

Case No. 2: New York City Soda Ban On September 13, 2012, New York City became the first city in the United States to ban the sale of sugar-loaded beverages, such as sodas larger than 16 ounces, at restaurants, arenas, movie theaters, and food carts (Park, 2012). If establishments did not abide by the ruling, they were subject to a $200 fine. While the concept was in support of the nationwide anti-obesity campaign and was largely supported by public health professionals, it was not very popular with residents. Why? People felt that a law limiting the amount of a product an individual could purchase infringes on personal rights.

In 2012, more than half of New York City adults and almost 40% of elementary and middle school children were overweight or obese (Park, 2012). Sugary drinks make up 43% of the added sugar in the average diet (Park, 2012). Most restaurants and other venues serving such drinks serve the products in 20-ounce glasses or larger. This adds a significant number of sugar/carbohydrate calories to an individual’s diet. Banning supersized beverages was seen as a means of reversing the city’s obesity trend and was approved by the board of health by a vote of 8–0 (Park, 2012).

At the time the law was presented for public comment, the members of the New York City Department of Health and Mental Hygiene and the New York City Board of Health found 32,000 comments favored the ban while only 6,000 opposed it. However, other consumer polls revealed that there was more opposition than support, and when the law was passed, it set off a city-wide uproar that quickly spread across the country.

Opponents of the law said it gave the government too much control over what they personally chose to eat or drink. Several groups petitioned the court to revoke the law. These groups had obtained more than a quarter million signatures from others who also felt the law infringed on their personal freedoms (Park, 2012).

A lawsuit was filed on October 12, 2012, in the New York Supreme Court asking for a reversal of the city’s law (N.Y. Statewide Coal. of Hispanic Chambers of Commerce v. N.Y.C. Dep’t of Health & Mental Hygiene, 2013). The petitioners did not dispute the obesity problem but noted that large drinks were not clearly connected to obesity. The coalition also claimed that the city’s health department “exceeded their authority and impermissibly trespassed on legislative jurisdiction” (N.Y. Statewide Coal. of Hispanic Chambers of Commerce v. N.Y.C. Dep’t of Health & Mental Hygiene, 2013, p. 10). In its decision, the court stated that “even under the broadest and most open ended of statutory mandates, an administrative agency may not use its author- ity as a license to correct whatever social evils it perceives” (p. 11). As a result of research, legal precedent (previous laws), and a lack of evidence that reducing the size of drinks sold would actually reverse the obesity crisis, the court overturned the law.

This is one instance in which a public health law did not have a solid connection to a com- munity’s health and well-being. The alleged greater good to help the public was not clearly defined and did far more damage to individual rights.

tongpatong/iStock/Thinkstock Does a public health law that bans the sale of large, sugary sodas in public restaurants and businesses infringe upon personal rights?

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Section 5.3 Public Health Ethics Cases

Case No. 3: Pelman v. McDonald’s In the 2003 case Pelman v. McDonald’s, two teens and their guardians filed a lawsuit against the fast food chain claiming that McDonald’s food caused obesity and increased the teens’ risk of other related diseases such as heart disease and diabetes. In the suit, the two girls claimed that the restaurant did not disclose the ingredients of its foods and the effects of eating such foods high in fat, salt, sugar, and cho- lesterol. This was considered a landmark case in the blame game of obesity. As thousands of people struggle with weight, lifestyles, and the temptation to eat unhealthy fast food, the nation watched this case closely to see if the legal system could deter- mine a root cause for the U.S. obesity epidemic.

The girls were Ashley Pelman and Jazlyn Bradley. At the time of the suit, 14-year-old Ashley Pelman was 4 feet, 10 inches tall and weighed 170 pounds, with a BMI of 35.5. Jazlyn Brad- ley, 17 years old, was 5 feet, 6 inches tall and weighed 270 pounds, with a BMI of 43.6 (Wald, 2003). The girls and their parents argued that McDonald’s should be held accountable for the girls’ obesity, heart disease, diabetes, high blood pressure, and elevated cholesterol. At the same time, several other cases were in the works. Caesar Barber, 56 years old, was suing McDonald’s, Wendy’s, Kentucky Fried Chicken, and Burger King for causing his two heart attacks and diabetes (Wald, 2003).

The U.S. District Court, Southern District of New York, heard both sides of the argument in 2003 and ruled in favor of McDonald’s. The legal basis for the case came when the teens alleged negligence on behalf of McDonald’s, stating that the restaurant distributed a prod- uct “that is so dangerous that its danger is outside the reasonable understanding of the con- sumer” (Pelman v. McDonald’s, 2003, p. 19). The court found this to be untrue, as the products in question were fully approved by the FDA and abided by laws such as food labeling and general requirements for health claims for foods. Furthermore, the plaintiffs had noted in court that they primarily ate at McDonald’s but not wholly, leaving room for questions about the remainder of their diets.

In the final judgment, the court stated that this was not a case of product liability, but one of overconsumption of products whose ingredients are widely known and available.

From an ethical standpoint, this case is intriguing because the plaintiffs focused on blame rather than personal responsibility. As issues crop up within the realm of ethics and morals, people tend to look outward rather than inward for a cause. Some would say this case was a waste of judicial resources when the individuals should have been focusing on their own health. Is this a trend in the United States? Are people now looking for someone to blame for their health issues instead of focusing on personal responsibility?

KatarzynaBialasiewicz/iStock/Thinkstock Are fast food restaurants accountable for an individual’s weight issues, or is the individual ultimately responsible for his or her food choices?

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Section 5.4 Policy and Law

5.4 Policy and Law Although the terms policy and law are often used interchangeably, the two are very different. A policy is a strategy or commitment to some type of action plan in the best interests of the general population. It often outlines a course of action that governmental bodies put together to achieve some long-term goal. A law is an enforceable piece of legislation that must happen and must be followed; if it is not followed, consequences will occur.

In public health, a policy typically includes laws, rules, and regulations that achieve the over- arching goal. However, the policy in itself is not an enforceable law. A policy typically starts with what is known as a policy brief. A brief is a summary of an issue that is being reviewed, the potential laws and action items that could tackle the problem, and recommendations on which would be the best approach (Food and Agricultural Organization of the United Nations, n.d.). Frankly, there is nothing brief about a policy brief.

There are two types of policy briefs: an advocacy brief and an objective brief (Public Health Law Center, 2015). The advocacy brief is a document that shows one side of an issue, typi- cally in favor of a particular course of action. The objective brief provides both sides of an issue, leaving the policy maker the opportunity to see all angles and make up his or her mind independently of the brief ’s author.

The policy brief provides lawmakers with an initial, complete view of the potential laws and actions that could address the overarching goal. If the policy brief is accepted in whole, all of the recommendations will eventually work their way into legislation. In some cases, only parts of a policy brief will be accepted and some of the recommendations will become laws. The next section explores how policies and laws work together in the public health realm.

Policy to Law in Action Public health professionals have developed numerous advocacy and objective briefs in an attempt to reduce the use of tobacco products. The overarching goal in the public health realm is to reduce the incidence of tobacco-related illnesses and deaths. To achieve this goal, laws must be in place to enforce healthy behaviors. As noted earlier, sometimes the health of the whole trumps the rights of the individual. When reviewing the issue of tobacco control and/ or elimination, public health professionals focus their attention on research that supports their view (advocacy policy) or that brings to light various alternatives (objective policy).

While a policy brief would be written in paragraph form as a document, Figure 5.2 is a hypo- thetical outline, including examples of what might be included in a policy brief.

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Section 5.4 Policy and Law

A goal, a goal statement, and actions that would help reach that goal are required elements of an effective policy brief that could eventually become law. In fact, the hope is that those actions would become supportive of the overall goal. A policy brief is only a suggested list of items. As each item becomes law, it is an enforceable set of rules.

In reality, some, but not all, of these suggested policy actions have become laws. Prohibiting or eliminating tobacco manufacturing in the United States would have created an economic upheaval. The last four bullet points in the policy actions section of Figure 5.2 did become law.

Figure 5.2: Policy brief outline

A policy brief is anything but brief, so this figure offers a condensed view. It shows the goals of a proposed policy, a policy statement, and actions—some of the key elements involved in developing a policy brief—for a tobacco example.

• Reduce tobacco deaths and illness

• Eliminate the use of tobacco products

• Enact tobacco controls that reduce or eliminate

the prevalence and incidence of tobacco

(smoking, chewing, etc.)

• Prohibit or limit the production of tobacco products in the U.S.

• Pass smoke-free ordinances for public spaces

• Restrict tobacco advertising

• Limit the age for tobacco product purchases

• Set minimum pricing for cigarettes and other tobacco products

Goal

Policy brief goal statement

Policy actions

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Section 5.4 Policy and Law

The removal of all tobacco manufacturers has been pondered numerous times in history. Bear- man, Neckerman, and Wright (2011) discovered that there would be a significant economic collapse if the tobacco industry were required to cease operating. While smoking reduction would certainly save lives, the billions of dollars in economic revenue would significantly hurt the United States. Furthermore, tobacco manufacturers donate a significant amount of money to public health and community development programs. For example, between 1997 and 2005, $143 billion was donated to charity from tobacco companies; 42% of that went into public and community funds. That money would no longer be available if the tobacco indus- try collapsed (Bearman et al., 2011).

Refer to Spotlight on Public Health Figures for information about a notable public health advo- cate from the 1800s, Sir Edwin Chadwick. His work helped to improve laws associated with living conditions among the poor in England.

Spotlight on Public Health Figures: Sir Edwin Chadwick (1800–1890)

Who is Sir Edwin Chadwick? Sir Edwin Chadwick was born in Manchester, England, in 1800. As a young boy, he was encouraged by his father to read, especially radical authors such as Thomas Paine. As a result of his father’s urging and interest in radical ideals, Chadwick decided to study law. He was not wealthy, so he funded his college education by writing for various publications on the topics of social change and the need for political reform. Chadwick spent his entire life focused on reforming the national laws regarding the poor.

What was the political climate at the time? The 1800s ushered in the Victorian era in Britain. Under Queen Victoria’s rule, Britain became the largest empire in the world and a mecca of financial security, and many people felt it a privilege to be ruled by such a great leader. Britain’s empire at the height of the Victorian age extended to about one fifth of the world’s population. But Chadwick did not see Britain as the world’s greatest nation due to its significant number of public health concerns. Cities were growing and becoming far more crowded and unsanitary. Cholera was a major issue during this time. Typhoid was another concern, and major cities in England experienced typhoid epidemics in 1837 and 1838. At the time, public health and sanitation were not keeping up with the cities’ growth spurts, and living conditions (especially among the poor) were directly causing poor health outcomes.

(continued)

Renfields_Garden/iStock/Thinkstock Sir Edwin Chadwick lived in Victorian England, when cities were crowded and conditions were often unsanitary. Sir Chadwick supported reforms and measures that improved living conditions among the poor.

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Section 5.4 Policy and Law

Public Health Laws All public health laws start as policies. Some are in depth and controversial, like the law of Prohibition, which was eventually revoked, and others are rather easily adopted, such as those regarding child safety seats. Public health laws focus on protecting the population as a whole or reducing injury, illness, and death. The following are a handful of the thousands of public health laws that have been keeping people in the United States safe for decades.

Prohibition In the 1920s, alcohol use and abuse was brought to the forefront of the country’s public health concerns. While the concept was well intended—reduce drinking and eliminate issues

Spotlight on Public Health Figures: Sir Edwin Chadwick (1800–1890) (continued)

What was his contribution to public health? Chadwick was one of the most influential public health activists of the 1800s. He was most passionate about political and social reform, which led him to investigate living conditions and poor sanitation. He pushed for social reforms and measures to improve ventilation, draining, and cleanliness of living conditions in order to build a happier community. Although he was a firm believer in miasma theory (which suggests all infectious diseases are spread through the air), he still focused his efforts on improving the living conditions of the poor to improve the overall health of England. Although Dr. John Snow proved that miasma theory was incorrect, Chadwick still focused on the link between poor living conditions and life expectancy.

What motivated him? As a lawyer, Chadwick believed he had significant power to effect change at the political and social levels. He leveraged this power to push through social improvements in England during the 1800s. He focused his attention on changing the Poor Law, which was a Victorian- era law that called for all parishes (local church communities) to take care of the poor by providing food, clothing, money, and housing. In those times, it was well known that the housing provided was subpar and contributed to poor health outcomes. Chadwick’s activism directly contributed to the development and passage of the 1834 Poor Law Amendment Act, which improved conditions in workhouses and provided food and clothing to all who resided in such housing.

Sources: Bloy, M. (2002). The 1601 Elizabethan Poor Law. Retrieved from http://www.victorianweb.org/history/poorlaw/elizpl.html Evans, E. (2011). Overview: Victorian Britain, 1837-1901. Retrieved from http://www.bbc.co.uk/history/british/victorians/overview _victorians_01.shtml National Archives Education Service. (n.d.). 1834 Poor Law. Retrieved from http://www.nationalarchives.gov.uk/documents /education/poor-law.pdf Science Museum. (n.d.). Edwin Chadwick (1800-90). Retrieved from http://broughttolife.sciencemuseum.org.uk/broughttolife/people /edwinchadwick Trueman, C. N. (2015). Edwin Chadwick. Retrieved from https://www.historylearningsite.co.uk/a-history-of-medicine/edwin-chadwick/

http://www.victorianweb.org/history/poorlaw/elizpl.html

http://www.bbc.co.uk/history/british/victorians/overview_victorians_01.shtml

http://www.nationalarchives.gov.uk/documents/education/poor-law.pdf

http://broughttolife.sciencemuseum.org.uk/broughttolife/people/edwinchadwick

https://www.historylearningsite.co.uk/a-history-of-medicine/edwin-chadwick/

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Section 5.4 Policy and Law

connected to alcoholism—it violated individual rights far more than expected. The outcry and underground operation of alcohol distillation and sales that followed were extensive.

Prohibition was clearly outlined in the 18th Amendment to the U.S. Constitution. It originally had a time limit for ratification, which was later removed. The remainder of the law contained the following:

Section 1. After one year from the ratification of this article the manufacture, sale, or transportation of intoxicating liquors within, the importation thereof into, or the exportation thereof from the United States and all territory subject to the jurisdiction thereof for beverage purposes is hereby prohibited.

Section 2. The Congress and the several States shall have concurrent power to enforce this article by appropriate legislation.

Section 3. This article shall be inoperative unless it shall have been ratified as an amendment to the Constitution by the legislatures of the several States, as provided in the Constitution, within seven years from the date of the submis- sion hereof to the States by the Congress. (State University of New York, 2018)

Leaders of the prohibition movement felt that a solid educational campaign would lead to a sober nation. It did work, as alcohol consumption dropped by 30% after the law went into effect (Ohio State University, 2018). What wasn’t considered was the ethical nature of such a law. How ethical was it to prohibit the consumption of a product? This was an ethical dilemma that involved both individuals and alcohol producers, who were not included in the decision to create the prohibition law.

Of interest, the 18th Amendment did allow for alcohol use when prescribed by a doctor, and it could be used for religious purposes and scientific reasons. To expand on the concepts included in the 18th Amendment, the Volstead Act was written (Hanson, 2018). The 25 pages of the Volstead Act outlined what was legal and what was illegal. (Refer to A Closer Look for more about the dos and don’ts in the Volstead Act.)

Prohibition lasted from 1920 to 1933, at which time repeal laws began. The 21st Amendment to the Constitution ended Prohibition on December 5, 1933. It is the only amendment in U.S. history that has ever been repealed.

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Section 5.4 Policy and Law

Speed Limits Speed limits originally provided information on road hazards rather than driver protection. For example, slower speed limits indicated to the driver that the road was winding or perhaps bumpy (Edwardson, 2002). As time passed and the safety of drivers and passengers became critical, the focus on speed limits was aligned more with personal safety—a public health concern.

The first type of speed limit began in the colony of New Amsterdam (now known as New York City). In 1652, a decree was issued stating that “no wagons, carts or sleighs shall be run, rode or driven at a gallop” or people would incur a fine equivalent to about $150 in today’s money (History Channel, 2018, para. 2). When the motorized vehicle hit the roads, there was no such thing as a “gallop” for these types of transportation, thus leading to the advent of speed limit legislation.

A Closer Look: The Volstead Act: An Explanation of Prohibition

The Volstead Act was written to clarify the 18th Amendment. It focused on what a person could and could not do in relation to alcohol consumption and purchase. Here are a few of the dos and don’ts outlined in the Volstead Act:

Legal:

• Drinking alcohol in your home or at a friend’s home • Buying alcohol with a medical prescription (one pint every 10 days) • Obtaining a permit to move alcohol if changing residences • Obtaining a permit to manufacture, sell, or transport alcohol if used for sacramental

or non-beverage use

Illegal:

• Carrying a hip flask • Giving alcohol as a gift • Taking or drinking alcohol in public places such as restaurants and hotels • Buying or selling homemade alcohol • Shipping alcohol to anyone for beverage use

Source: Adapted from “Prohibition Laws and Repeal Laws in the U.S.” [web post], by D. J. Hanson, 2018, in Alcohol Problems and Solutions (https://www.alcoholproblemsandsolutions.org/volstead-act-national-prohibition-act-of-1919/). Copyright 1997–2015 by D. J. Hanson, State University of New York.

https://www.alcoholproblemsandsolutions.org/volstead-act-national-prohibition-act-of-1919/

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Section 5.4 Policy and Law

Connecticut was the first state to pass a speed limit law, in 1901. All motor vehicles were required to drive a maximum speed of 12 mph in all cities, and 15 mph on other roads. Two years later, New York City adopted the world’s first comprehensive traffic code. William Phelps Eno, known as the father of traffic safety, developed the code and later also traffic plans for New York City, London, and Paris. He was also credited with inventing stop signs, one-way streets, taxi stands, traffic circles, and pedestrian safety islands—all in the name of public health safety (Eno Center for Transportation, n.d.-a). Refer to Spotlight on Public Health Figures for more about Eno’s contributions to public health.

Spotlight on Public Health Figures: William Phelps Eno (1858–1945)

Who is William Phelps Eno? Eno, known as the father of traffic safety, was a pioneer of traffic control and regulation. Born on June 3, 1858, in New York City, Eno was raised in a wealthy family of businessmen and politicians. He graduated from Yale University, started his career in the family’s real estate business, and later followed his interests into public transportation.

What was the political climate at the time? At the time, Eno was focused on transportation, the United States had established itself as a world power, the entire continent had been settled, and the war with the American Indians seemed to be over. American society was focused on industrial capacity, especially in the production of steel, as well as the newly invented gas-powered engine car. Telephones were widely used, and access to electricity was spreading across the country. The United States triumphed in the Spanish-American War of 1898. President William McKinley was assassinated in 1901—at which time Theodore Roosevelt assumed the office.

What was his contribution to public health? Eno was the first person to create transportation safety rules. He called them “rules of the road.” Adopted by New York City in 1909, these rules constituted the world’s first city traffic plan. Eno popularized stop signs, pedestrian safety islands, and other safety features that are still used today for traffic control.

(continued)

ClassicStock.com/SuperStock William Phelps Eno created some of the earliest traffic rules and features, such as stop signs and pedestrian islands, to enhance transportation safety.

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Section 5.4 Policy and Law

Safety and speed limit laws were slowly adopted across the United States. Only 28 states had such laws by 1930 (American Safety Council, 2014). In 1974, President Richard Nixon signed a national law requiring a maximum speed limit of 55 mph (American Safety Council, 2014). By this point, public health was driving the move to limit automotive speed. The 1970s oil and gas shortage also spurred conservation measures to reduce the consumption of gas and oil. Both efforts had the public health benefit of successfully reducing traffic fatalities from 4.28 million in 1972 to 2.73 million in 1983 (American Safety Council, 2014). In 1987, speed limits were increased nationally to 65 mph, and later, the National Highway System Designation Act of 1995 repealed the national speed limit, allowing states to control their own speeds. This is why some states allow 70 mph maximum speeds when others still limit the speed to 55 mph.

There is an ongoing debate about freedom versus regulation in terms of speed limits. Since the 1995 act, which allowed traffic speeds to be determined at the state level, the num- bers of fatalities on highways that allow a maximum speed above 65 mph have gradually increased, as shown in Figure 5.3. Public health safety professionals are still tackling the issue of speeding—more than 300 years after it was first addressed in the U.S. colonies.

Spotlight on Public Health Figures: William Phelps Eno (1858–1945) (continued)

What motivated him? When he was 9, he and his mother were caught in a traffic jam of horses and carriages in New York City. The jam was created by a lack of order at an intersection—no one knew who had the right of way. That specific event remained with Eno for years. He felt that increased traffic resulted in increased confusion. He took it upon himself to develop a traffic plan, which was the beginning of what is now known as the rules of the road. Eno never learned how to drive, but he was issued an honorary driver’s license.

Sources: Blazeski, G. (2016, November 16). The man who invented stop signs, one-way streets, never passed his driving test. The Vintage News. Retrieved from https://www.thevintagenews.com/2016/11/16/the-man-who-invented-stop-signs-one-way-streets-never -passed-his-driving-test/ Eno Center for Transportation. (n.d.). William Phelps Eno. Retrieved from https://www.enotrans.org/about-eno/mission-history/ Library of Congress. (n.d.). America at the turn of the century: A look at the historical context. Retrieved from https://www.loc.gov /collections/early-films-of-new-york-1898-to-1906/articles-and-essays/america-at-the-turn-of-the-century-a-look-at-the -historical-context/

https://www.thevintagenews.com/2016/11/16/the-man-who-invented-stop-signs-one-way-streets-never-passed-his-driving-test/

https://www.enotrans.org/about-eno/mission-history/

https://www.loc.gov/collections/early-films-of-new-york-1898-to-1906/articles-and-essays/america-at-the-turn-of-the-century-a-look-at-the-historical-context/

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School Vaccination Before 1922, children did not have to be vaccinated to attend school. As noted in Chapter 3, communicable diseases were common until vaccines were invented to prevent them. Vac- cines have created herd immunity, which protects the public from these diseases. Schools contain hundreds and sometimes thousands of people gathered in one place. This is a breed- ing ground for communicable diseases, and without vaccines, illnesses would spread easily and quickly.

All 50 states require vaccinations for children to attend either public or private school. There are some exceptions based on religious and medical reasons. But if herd immunity is achieved, then population protection holds despite these exceptions. However, in cases where there is not herd immunity, a disease outbreak can occur. An example of this is the 2014 measles out- break in California that affected hundreds of children (Barraza, Schmit, & Hoss, 2017). The cause? There were too many exceptions to the vaccination rule. Since then, stricter rules on exemptions have been exacted across nearly every state.

Figure 5.3: Speeding-related fatalities by speed limit, 1983–2002

Since the National Highway System Designation Act of 1995, which allowed traffic speeds to be determined at the state level, the numbers of fatalities on highways that allow a maximum speed above 65 mph have gradually increased. It may be important to revisit the law and create a standard across the United States.

Source: Adapted from “Analysis of Speeding-Related Fatal Motor Vehicle Traffic Crashes,” by Department of Transportation, 2005 (https://safety.f hwa.dot.gov/speedmgt/data_facts/).

Year

50 mph and below 55 mph 60–65 mph Above 65 mph

N u

m b

e r

o f

fa ta

li ti

e s

1980 1985 1990 1995 2000 2005

10,000

9,000

8,000

7,000

6,000

5,000

4,000

3,000

2,000

1,000

https://safety.fhwa.dot.gov/speedmgt/data_facts/

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Section 5.4 Policy and Law

The impact of vaccinations is astounding and considered one of the biggest accomplish- ments of public health. But the law played an important role in this triumph. It is important to remember that once vaccines became available, they were not legally required. To eradicate various diseases, public health professionals petitioned lawmakers with policy briefs, which outlined the various actions that would lead to their stated goal. One of those key actions was the requirement of vaccinations. Thus began an era of reduced infectious diseases and the eradication of many others. Table 5.4 shows the decline from the 20th century to the year 2000 (the start of the 21st century).

Table 5.4: Comparing historical and current morbidity of vaccine-preventable diseases of children in the United States

Disease

Annual morbidity Percentage

decreaseDuring the 20th century* 2000

Smallpox 48,164 0 100

Diphtheria 175,885 4 99.99

Measles 503,282 81 99.98

Mumps 152,209 323 99.80

Pertussis 147,271 6,755 95.40

Polio (paralytic) 16,316 0 100

Rubella 47,745 152 99.70

Influenza type B 20,000 167 99.10

*Typical average during the 3 years before vaccine licensure.

Source: Adapted from “Vaccine Mandates: The Public Health Imperative and Individual Rights,” by K. M. Malone and A. R. Hinman, in R. A. Goodman, R. E. Hoffman, W. Lopez, G. W. Matthews, M. Rothstein, and K. Foster (Eds.), Law in Public Health Practice (2007, pp. 338–360). Oxford, England: Oxford University Press.

Seat Belts Title 49 of the United States Code, Chapter 301, Motor Vehicle Safety Standard, required the installation of seat belts in all vehicles with the exception of buses (U.S. Code, Title 49 – Trans- portation, 2009). That law went into effect on January 1, 1968; however, the requirement to use seat belts did not occur until the mid-1980s, almost 20 years later.

The National Highway Traffic Safety Administration (2000) reported the effects of the law on fatalities and found some astounding results, as shown in Table 5.5. Since the inception of the seat belt law, the nation has seen a tremendous reduction in motor vehicle accident deaths. This is yet another way the law is intertwined with public health.

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Section 5.4 Policy and Law

Vehicle Emissions Clean air responsibilities also fall into the public health realm. Poor air quality has caused various respiratory diseases such as asthma and lung cancer. It has also been connected to cardiovascular diseases, adverse pregnancy outcomes such as preterm birth or death, and a lower quality of life (National Institutes of Health, 2017a).

When motor vehicles were invented, no one truly thought about the consequences of air pol- lution. After World War II, economic growth, rapid suburbanization, and an extensive trans- portation boom led to a significant increase in air pollution. It wasn’t until the Clean Air Act of 1970 that public health officials began focusing on regulating pollution from cars, trucks, and other forms of transportation (EPA, 2017).

The Clean Air Act was a success because it not only set the bar for strict regulations on car emissions, but also laid the foundation for policies and laws to guide future standards for cleaner air. As a direct result of the 1970 act, new passenger vehicles were 98%–99% cleaner, in terms of tailpipe emissions, than their 1960s counterparts. Fuels have also become cleaner because of the elimination of lead and sulfur levels. Cities have seen significant air quality improvements despite an increase in population and vehicle miles traveled daily. This also has led to more pollution-reducing laws and policies across various industries that release pollution into the air. See Figure 5.4 to compare emissions from 1980 to 2015.

Table 5.5: Fatalities of belted and unbelted drivers and passengers, 1977–1985

Driver died, front passenger survived

Driver survived, front passenger survived Both died

Both unbelted 11,186 11,469 5,317

Driver unbelted, passenger belted 300 152 74

Driver belted, passenger unbelted 186 487 102

Both belted 497 653 242

Note: n = 30,665 vehicles

Source: Adapted from Fatality Reduction by Safety Belts for Front-Seat Occupants of Cars and Light Trucks (Report No. 809 199), by National Highway Traffic Safety Administration, 2000, Washington, DC: U.S. Department of Transportation.

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Section 5.4 Policy and Law

National School Lunch Program In 1946, providing nutritionally balanced, low-cost or free lunches to children K–12 in both public and private schools every day became a requirement (U.S. Department of Agriculture [USDA], 2017a). The lunch program started as an effort to help feed children who lived in poverty. In fact, the effort of school lunches (and now breakfasts) began following the 1904 publication of a book by Robert Hunter called Poverty (USDA, 2017b). This book, which exam- ined widespread hunger among children, had a strong influence on the U.S. decision to work within the school systems to bring nutritional lunches to poverty-stricken students (USDA, 2017b).

Figure 5.4: Comparison of growth areas and emissions, 1980–2015

The choices we make can affect air pollution. For example, emissions increase as more vehicles are on the roads or the population increases. Emissions also increase along with the gross domestic product. This is a significant problem that is currently being reviewed at local, state, and federal levels (but clean air policies have also contributed to air quality improvements).

Source: Adapted from “History of Reducing Air Pollution From Transportation in the United States (U.S.),” by Environmental Protection Agency, 2017 (https://www.epa.gov/air-pollution-transportation/accomplishments-and-success-air-pollution-transportation).

Vehicle miles traveled

Gross domestic product Population Aggregate emissions (six common pollutants)

CO2 emissions

Energy consumption

P e rc

e n

t g

ro w

Year

1980 1985 1990 1995 2000 2005 2010 2015

153%

106%

41%

25%

18%

-65%

160%

140%

120%

100%

80%

60%

40%

20%

-20%

-40%

-60%

-80%

https://www.epa.gov/air-pollution-transportation/accomplishments-and-success-air-pollution-transportation

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Section 5.4 Policy and Law

It wasn’t until more than four decades after the publication of Poverty that policy makers stepped in to make school lunch programs a requirement. About 7.1 million children partici- pated in the program in its first year (USDA, 2017a). Since then, the program has blossomed, bringing much-needed food to children across the country. Figure 5.5 shows how participa- tion levels have risen since 1970.

Figure 5.5: National participation levels of school lunch programs

About 7.1 million children participated in the National School Lunch Program in its first year. Since then, the program has blossomed, bringing much-needed food to children across the country. This graph shows participation rates over time.

Source: Adapted from “National School Lunch Program,” by U.S. Department of Agriculture, 2017 (https://fns-prod.azureedge.net/sites /default/files/cn/NSLPFactSheet.pdf ).

Year

P a rt

ic ip

a ti

o n

i n

m il li o

n s

1960 1970 1980 1990 2000 2010 2020

22.4

26.6

21.1

27.3

31.8 30.4

Without the law, school lunch programs might not have ever become a school requirement. Poverty has been associated with poor health outcomes and, therefore, has been a topic of public health for decades. Laws that implement programs such as this one have helped to eliminate some of that burden.

https://fns-prod.azureedge.net/sites/default/files/cn/NSLPFactSheet.pdf

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Section 5.4 Policy and Law

The law now includes a nutrition standard for those meals served at school, which was approved in January 2012 (USDA, 2012). Under this rule, schools are required to:

• Offer fruits and vegetables as two separate meal components;

• Offer fruit daily at breakfast and lunch; • Offer vegetables daily at lunch, includ-

ing specific vegetable subgroups weekly (dark green, orange, legumes, and other as defined in the 2005 Dietary Guidelines) and a limited quantity of starchy vegetables throughout the week;

• Offer whole grains: half of the grains would be whole grain-rich upon implementation of the rule and all grains would be whole- grain rich two years post implementation;

• Offer a daily meat/meat alternate at breakfast;

• Offer fluid milk that is fat-free (unflavored and flavored) and low-fat (unflavored only);

• Offer meals that meet specific calorie ranges for each age/grade group; • Reduce the sodium content of meals gradually over a 10-year period through two

intermediate sodium targets at two and four years post implementation; • Prepare meals using food products or ingredients that contain zero grams of trans

fat per serving; • Require students to select a fruit or a vegetable as part of the reimbursable meal; • Use a single food-based menu planning approach; and • Use narrower age/grade groups for menu planning. (USDA, 2012, p. 4088)

The rule also requires state agencies to:

• Conduct a nutritional review of school lunches and breakfasts as part of the adminis- trative review process;

• Determine compliance with the meal patterns and dietary specifications based on a review of menu and production records for a two-week period; and

• Review school lunches and breakfasts every 3 years, consistent with the HHFKA [Healthy Hunger-Free Kids Act]. (USDA, 2012, pp. 4088–4089)

There are numerous laws and regulations for school food programs, but these are the larger ones that affect all lunch and breakfast programs now served in K–12 schools around the United States.

JGI/Jamie Grill/Blend Images/SuperStock School lunch programs can help ensure that all children, especially those who live in poverty, have access to nutritious foods on school days.

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Summary & Resources

Chapter Summary Ethics and the law work in conjunction with public health. In fact, some would say that public health couldn’t exist without the law. This chapter covered a fraction of public health law and policy concerns; there are thousands more instances where the law has stepped in to help the public health realm.

Ethics are the principles that govern a person’s behavior; they are rules provided by an exter- nal source, such as codes of conduct in a workplace. Morals are an individual’s principles of right and wrong. They inform standards of behaviors or beliefs concerning acceptable behavior for individuals. The code of ethics for public health practitioners provides details on how public health utilizes all of these concepts in its decision-making process. The Principles for the Practice of Public Health Ethics, developed by the Public Health Leadership Society, is the foundational document used by nearly all public health professionals and public health– focused organizations. Most decisions are not cut and dried and require a significant amount of critical thought in application to the ethical practice of public health. The code provides a blueprint for reviewing all issues before decisions are made.

Ethics and the law can clash considerably, and the courts have faced numerous cases where personal rights and public protections needed to be considered. The Jacobson v. Massachu- setts case illustrated the tension between personal freedom and public health protections in compulsory vaccinations. The New York State soda ban, which was repealed before it was enacted, exemplified personal choice versus governmental interference. Personal responsi- bility in nutrition was highlighted in Pelman v. McDonald’s, in which two teens claimed the fast food chain made them fat. Public health’s role is to intercede when the population’s health is at risk. Sometimes, that conflicts with a person’s morals or a community’s ethics. But public health works to improve population well-being by following community-based, rather than individual, ethics.

Policy and law are also key elements in the administration of public health. A policy is a docu- ment that outlines what an organization or government agency is planning to do for the popu- lation. It is not a law, but it can become a law if it is approved by Congress and signed by the president. Laws, such as wearing a seat belt while driving a car, help protect the population. Policies provide the background to support such laws. For instance, a community may have a policy to provide fresh fruit to all local stores but may not be able to fully act on it depending on a number of variables (transportation, the agricultural industry, cost, etc.). One example of the transformation from policy to law is limits on tobacco use. To reduce smoking, a policy might be to dismantle the tobacco industry. Because of the surrounding ethical issues, this type of policy is unlikely to become a law. However, some tobacco policies—such as no smok- ing in public places—have become law in many states. There are many policies that have become law in the public health realm, including speed limits, limits on vehicle emissions, and the National School Lunch Program.

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Summary & Resources

Critical Thinking and Review Questions

1. What is the difference between morals and ethics? 2. What role does ethics play in public health? 3. What does the Public Health Code of Ethics mean for public health? For the general

population? 4. Consider the Principles of the Ethical Practice of Public Health, developed by the

Public Health Leadership Society. Explain at least two of the principles and why you believe they were included in this document.

5. In reviewing the Jacobson v. Massachusetts case, why do you think that Jacobson believed his personal rights were violated?

6. If we are given personal freedoms as per the U.S. Constitution, why do some laws seemingly remove that freedom by requiring us to behave in a specific way (no smoking in public places, wearing a helmet while riding a motorcycle)?

7. What is the difference between a policy, a policy brief, and a law? 8. Explain one example of how the law is used in public health. 9. Consider one area of need in your community. How could a law or policy help to

address that issue? 10. Consider William Phelps Eno’s work in traffic control. Do you think it has been effec-

tive? How could it be improved?

Additional Resources

Case laws of interest

https://biotech.law.lsu.edu/cases/food/index.htm Review court cases that focus on food safety and ethics.

The CDC ethics cases and curriculum

https://www.cdc.gov/od/science/integrity/phethics/resources.htm The Centers for Disease Control and Prevention provides open access to public health ethics cases and curriculum.

United Nations Universal Declaration of Human Rights

http://www.un.org/en/universal-declaration-human-rights/ This is the Universal Declaration of Human Rights as outlined and approved by the United Nations. It is an ethical statement of what countries in the United Nations have agreed upon in regard to human rights.

https://biotech.law.lsu.edu/cases/food/index.htm

https://www.cdc.gov/od/science/integrity/phethics/resources.htm

http://www.un.org/en/universal-declaration-human-rights/

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Summary & Resources

Key Terms advocacy brief A policy document that shows one side of an issue, typically in favor of a particular course of action.

clinical ethics Ethics addressing issues that arise within the patient care realm.

ethics The principles that govern a person’s behavior, as provided by an external source such as codes of conduct in a workplace or a community.

law An enforceable piece of legislation that must happen and must be followed; if it is not followed, consequences will occur.

morals An individual’s principles of right and wrong.

objective brief A policy document that pro- vides both sides of an issue, leaving the pol- icy maker the opportunity to see all angles and make up his or her mind independently.

policy A strategy or a commitment to some type of action plan that will tackle an issue and could potentially become law.

policy brief A concise summary of an issue that is being reviewed that includes several recommendations that may become indi- vidual policies.

research ethics Ethics involving the pro- tections of human subjects who are taking part in a study.