An outline for ethics in public health

Policy & Management Blog GPH2110

            In their article Ethical analysis in public health, Dr. Roberts and Dr. Reich explore ethical frameworks related to public health policy building considering the perspectives of utilitarianism, liberalism, communitarianism and feminism (2002). They argue that ethical frameworks, while common in the medical community, are distinctly lacking yet necessary in the public health discourse in the face of complex ethical dilemmas. Below I will outline the philosophical views they explore and the strengths and weaknesses of each approach as related to public health.

Utilitarianism: The consequences are important related to affecting the best outcome for the greatest number of people.

Two subgroups noted are:

  • Subjective: The outcomes of a utilitarian approach are best defined by the individual’s personal experience.
  • Objective: A generalized, expert-designed assessment process to determine outcomes is preferred. The author’s give the examples of DALY’s and QALY’s.

Strengths: Ultimately, the approach strives to improve individual and overall well-being.

Weaknesses: There may be a loss of individual rights when attempting to support the greatest good for the population. The authors give the example of quarantining HIV+ people in Cuba to prevent spread of the disease.

Liberalism: Individual rights should be preserved above all.

Two subgroups noted are:

  • Libertarians: Prefer minimal state influence, used only to protect personal liberties and property rights, or “negative rights,” as the authors explain.
  • Egalitarian liberals: They maintain the foundation that there are minimum resources needed in order to for an individual to maintain their right to choose.

Within this framework, it is argued whether health is a prerequisite for the ability to make choices, or health is a result of choices made.

Strengths: Allows for population level priority-setting.

Weaknesses: Unclear what the minimum resources would be for an individual. It is unclear how children and/or the mentally ill would fit into this framework. The authors point out that these approaches do not address social structures. Given that, you should not value your family over a stranger, for example.

Communitarianism: Varying viewpoints related to creating a “good society.”

Among several differing subgroups/approaches noted, the two highlighted are:

  • Communitarians: Each individual community should define its own virtuous norms (virtue is contextual).
  • Universalist communitarians: As the authors state, “..there is a single, true form of good society…”.

Strengths: May allow for cultural practices.

Weaknesses: Difficult to define community boundaries. Danger of extremism.

Ethics-of-care feminism: A consequentialist approach based on caring relationships and acknowledging “fundamental inequalities of power, capacity, judgment, information and responsibility” related to family life.

Strengths: Acknowledges power dynamics and intricacies of family and personal life. Allows for empathy.

Weaknesses: May be challenging to apply at the population level.

Justification/meta-ethics: The authors describe this area as “questions about the nature of ethics itself”

The approaches they outline are: religious, emotional/intuitive, logic-based, moral realism (indicating that morals can be learned through experience), and postmodern (“acceptance of moral views that work to make the world a better place.”).

Benefit of using an ethical framework in public health discourse:

The authors suggest transparency in decision-making process and discussion as a key role of working within a given ethical framework.

Some critiques of the article:

I am not sure why the authors discuss the ethics-of-care feminism as a sort of afterthought; it seemed a strange outline for the article.

I felt that the authors offered a poor/inaccurate argument against the utilitarian approach related to organ transplant allocation in US, reporting a “sickest first” approach. That is far from the reality of how organs are allocated (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC324738).

All information above is in reference to the following article:

Roberts, M. & Reich, R. (2002). Ethical analysis in public health. The Lancet, 359, 1055-1059.

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