after 18 hours

July 2002, Vol 92, No. 7 | American Journal of Public Health Editorial | 1057

⏐ EDITORIAL

A Code of Ethics for Public Health

The mandate to ensure and pro- tect the health of the public is an inherently moral one. It carries with it an obligation to care for the well-being of communities, and it implies the possession of an element of power to carry out that mandate. The need to exer- cise power to ensure the health of populations and, at the same time, to avoid abuses of such power are at the crux of public health ethics.

Until recently, the ethical na- ture of public health has been im- plicitly assumed rather than ex- plicitly stated. Increasingly, however, society is demanding ex- plicit attention to ethics. This de- mand arises from technological advances that create new possibil- ities and, with them, new ethical dilemmas; new challenges to health, such as the advent of HIV; and abuses of power, such as the Tuskegee study of syphilis.

Medical institutions have been more explicit about the ethical elements of their practice than have public health institutions. However, the concerns of public health are not fully consonant with those of medicine. Thus, we cannot simply translate the princi- ples of medical ethics to public health. In contrast to medicine, public health is concerned more with populations than with indi- viduals, and more with prevention than with cure. The need to artic- ulate a distinct ethic for public health has been noted by a num- ber of public health professionals and ethicists.1–5

A code of ethics for public health can clarify the distinctive elements of public health and the ethical principles that follow from or respond to those elements. It

can make clear to populations and communities the ideals of the pub- lic health institutions that serve them, ideals for which the institu- tions can be held accountable.

THE PROCESS OF WRITING THE CODE

The backgrounds and perspec- tives of people who identify themselves as public health pro- fessionals are as diverse as the multitude of factors affecting the health of populations. Articulating a common ethic for this diverse group is a formidable challenge. In the spring of 2000, the gradu- ating class of the Public Health Leadership Institute chose writing a code of ethics for public health as a group project. The institute provides advanced leadership training to people who are al- ready in leadership roles in pub- lic health. Because the fellows bring a wealth of experience from a wide variety of public health in- stitutions, they are uniquely able to represent diverse perspectives and identify ethical issues com- mon in public health.

At the 2000 meeting of the Na- tional Association of City and County Health Officers, the group added a non-institute member ( J. C. Thomas) and charted a plan for working toward a code. The plan included receiving a formal charge as the code of ethics work- ing group at the annual meeting of the American Public Health Asso- ciation (APHA); reviewing codes written by other organizations, particularly those within public health (the American College of Epidemiology and the Society of Public Health Education); and bal-

ancing open participation with ef- ficiency in writing the code.

The latter aim was achieved by having a small number of people write an initial code, then inviting feedback on it and each succes- sive version from progressively broader audiences. The audi- ences reacting to the code drafts were (1) the working group itself; (2) an additional 19 ethicists and representatives from various pub- lic health agencies gathered in a meeting at the University for Health Sciences in Kansas City to critique the code; and (3) APHA members (via the APHA Web site, where the code was posted and feedback was solicited, and the 2001 annual meeting).

THE CONTENT OF THE CODE

The consensus reached during the review process was that while people outside the public health establishment might find the code useful, it should be directed to those in traditional public health institutions, including public health departments and schools of public health. Similarly, while people working in public health throughout the world may find the code helpful, it was written with the American public health system in mind. Although touch- ing on aspects of research, the focus of the code is principally on public health practice.

While acknowledging the value of a set of principles for individu- als, and the fact that institutional policies are often carried out by individuals, the working group wrote the code for institutions. One reason was the definition of

⏐ EDITORIAL ⏐

American Journal of Public Health | July 2002, Vol 92, No. 71058 | Editorial

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 for, or work for the empowerment of, disenfranchised

community members, ensuring that the basic resources and conditions necessary for

health are accessible to all people in the community.

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.

public health first articulated in the Institute of Medicine report The Future of Public Health and used in the code: “What we, as a society, do collectively to assure the conditions for people to be healthy.”6 Others have also noted that one of the differences be- tween public health and medicine is that public health is most often delivered by government institu- tions to a population rather than by one person to another.3

The writers of the code aimed for a document that could fit on a single page and be easily posted. This concise statement of 12 ethi- cal principles (box on this page) is accompanied by a series of other documents, including a preamble that explains the purpose of the code; a list of 14 values and be-

liefs inherent to a public health perspective that underlie the ethi- cal principles; and notes on the ethical principles to more fully explain their intent. (All of the components are posted on the Web, and are available at http:// www.apha.org/codeofethics.)

Reviewers of the code pre- ferred positive rather than nega- tive wording of the ethical princi- ples. For example, the principle addressing conflicts of interest (number 12) is worded as an affir- mation of collaboration with the proviso that it be done in a way that enhances the public’s trust in the institutions.

The code draws upon several ethical concepts. The more indi- vidualistic notion of human rights appears in the second principle as

a necessary point of tension with the communitarian concern for the well-being of communities. Theories of distributive justice un- derlie the fourth principle, which speaks of the need for basic re- sources and conditions necessary for health among the disenfran- chised. Duty as an ethical motiva- tion is represented in several of the principles, such as the obliga- tions to provide information in some instances and to protect it in others.

One of the beliefs inherent to a public health perspective is that each person both affects and de- pends upon others. This interde- pendence between humans un- derlies the most fulfilling aspects of relationships and community as well as conflicts between peo- ple. Interdependence is the com- plement to autonomy, a domi- nant principle in medical ethics. Without denying that individuals have a right to some role in deci- sions that affect them, a recogni- tion of interdependence serves as a correction to an overly individ- ualistic perspective that is incon- sistent with public health’s con- cern with whole communities and populations.

The principle of interdepend- ence between individuals lies be- hind the preeminence given to the health of communities in the 2nd principle of the code. Interdepen- dence between institutions and the need for collaboration under- lies the 12th principle, and the in- terdependence inherent to ecolog- ical systems underlies the 9th principle, which addresses the physical and social environments.

DISSEMINATION AND ADOPTION OF THE CODE

For the code to be truly useful it must be broadly disseminated and adopted by public health in-

stitutions. Adoption by key na- tional agencies and organizations will imbue the code with a de- gree of moral authority that will increase both its utility and the likelihood that it will be adopted and used by national, state, and local institutions. On February 26, 2002, the APHA Executive Board formally adopted the code, making APHA the first na- tional organization to do so. This endorsement provides the code of ethics working group with an important tool for talking about adoption with other organiza- tions and agencies, such as the Centers for Disease Control and Prevention, the National Associa- tion of City and County Health Officers, the Association of State and Territorial Health Officials, and the Association of Schools of Public Health. Members of these institutions contributed to the creation of the code, which should help with the next step of adoption.

Once a government agency or professional organization adopts the code, it will need to build these ethical principles into its policies and procedures, to the extent that it has not already done so, and train its employees in ways that ensure the imple- mentation of the principles. Schools of public health should teach the code to their students. Since many public health profes- sionals do not have a formal de- gree in public health, there will also be a need for continuing ed- ucation or extension courses that include the code of ethics and how to use it.

For each of these tasks there will be a need for new tools. These might include materials for teaching the code, such as case studies illustrating the appli- cation of each of the 12 ethical principles; a workbook that helps

⏐ EDITORIAL ⏐

July 2002, Vol 92, No. 7 | American Journal of Public Health Editorial | 1059

an institution consider how it might build the ethical principles into its policies and practices; and an oath to be recited by indi- viduals as they graduate from a school of public health or as they are hired by a public health insti- tution (the code of ethics working group is now considering writing such an oath).

FUTURE IMPROVEMENTS

The code of ethics, as it now stands, is the first explicit state- ment of ethical principles inher- ent to public health. It is a signifi- cant step forward, but it is unlikely to be the last step. Al- though the code was developed with broad input, we will gain new insights about its strengths and weaknesses as it is imple- mented. Moreover, as the world changes, public health profes- sionals will become sensitized to new ethical issues. We anticipate, then, a time when the code will need to be updated.

To facilitate this process, the code will be posted on the Web in an interactive format that will welcome comments and will allow people to read others’ com- ments. A standing committee of the Public Health Leadership So- ciety will actively engage public health professionals and ethicists in the consideration of periodic updates to the code, which will incorporate lessons learned and comments received over time. In the near future, however, the code should prove to be a useful tool in clarifying the values and purposes of the public health pro- fession and enabling it to more often achieve its high ideals.

James C. Thomas, MPH, PhD Michael Sage, MPH

Jack Dillenberg, DDS, MPH V. James Guillory, DO, MPH

About the Authors James C. Thomas is with the Department of Epidemiology and the Program in Public Health Ethics, University of North Car- olina School of Public Health, Chapel Hill. Michael Sage is with the National Center for Environmental Health, Centers for Dis- ease Control and Prevention, Atlanta, Ga. Jack Dillenberg is with the School of Den- tistry and Oral Health, Arizona School of Health Sciences, Phoenix. V. James Guillory is with the Department of Preventive Medi- cine and Division of Research, University of Health Sciences, Kansas City, Mo.

Requests for reprints should be sent to James C. Thomas, MPH, PhD, 2104-B McGavran-Greenberg Hall, CB#7435, School of Public Health, University of North Carolina, Chapel Hill, NC 27599- 7035 (e-mail: [email protected]).

This editorial was accepted April 10, 2002.

Acknowledgments The writing of the code of ethics was funded in part by the Centers for Dis- ease Control and Prevention, both di- rectly and through funding of the Public Health Leadership Society.

The authors thank the other mem- bers of the code of ethics working group: Elizabeth Bancroft (Centers for Disease Control and Prevention, Los An- geles County), Kitty Hsu Dana (APHA), Joxel Garcia (Connecticut Department of Health), Kathleen Gensheimer (Maine Department of Health), Teresa Long (Columbus, Ohio, Department of Health), Ann Peterson (Virginia Depart- ment of Health), Liz Schwarte (Public Health Leadership Society), Kathy Vin- cent (Alabama Health Department), and Carol Woltring (Center for Health Lead- ership and Practice, Oakland, Calif).

References 1. Mann JM. Medicine and public health, ethics and human rights. Hastings Center Rep. 1997(May-Jun);27:6–13.

2. Beauchamp D. Community: the ne- glected tradition of public health. In: Beauchamp D, Steinbock B, eds. New Ethics for the Public’s Health. New York, NY: Oxford University Press; 1999.

3. Kass NE. An ethics framework for public health. Am J Public Health. 2001; 91:1776–1782.

4. Callahan D, Jennings B. Ethics and public health: forging a strong relation- ship. Am J Public Health. 2002;92: 169–176.

5. Roberts MJ, Reich MR. Ethical analysis in public health. Lancet. 2002; 359:1055–1059.

6. Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1988.

American Public Health Association Publication Sales Web: www.apha.org E-mail: [email protected] Tel: (301) 893-1894 FAX: (301) 843-0159

Suitable for classroom discussions andprofessional workshops, this book of edited public health case studies illus- trates the ethical concerns and problems in public health research and practice. The sixteen chapters cover privacy and confidentiality protection, informed con- sent, ethics of randomized trials, the insti- tutional review board system, scientific misconduct, conflicting interests, cross- cultural research, genetic discrimination, and other topics. An instructor’s guide is also provided at the end.

ISBN 0-87553-232-2 1997 ❚ 182 pages ❚ softcover

$26.00 APHA Members $37.00 Nonmembers

plus shipping and handling

Case Studies in Public Health Ethics By Steven S. Coughlin, PhD, Colin L.

Soskolne, PhD, and Kenneth W. Goodman, PhD

ET02J2

⏐ EDITORIAL ⏐

American Journal of Public Health | July 2002, Vol 92, No. 71060 | Editorial