How does the field of public health—given its role in making decisions that impact entire populations—define ethics? How can it be used to advance health equity and social justice? These are some of the questions explored at the 150th annual meeting of the American Public Health Association (APHA)—a network of over 25,000 public health professionals—in November 2022.
“Ethical values are critical to all that we do,” says Dr. Nancy Krieger, a professor of social epidemiology at Harvard T.H. Chan School of Public Health. During a closing plenary session entitled “Building Public Health Capacity Through an Ethical Lens to Address Social Challenges,” public health leaders discussed their perspectives on the need for a clearer, more transparent focus on ethical decision-making when addressing population health. Dr. Krieger was joined by fellow panelists Dr. Lisa Lee (Associate Vice President of Research and Innovation at Virginia Tech), Dr. Reuben Warren (Director of the National Center for Bioethics in Research and Health Care at Tuskegee University), and Dr. David Holtgrave (Assistant Director for Translational Research in the White House Office of National Drug Control Policy).
The theme of the discussion—moderated by Dr. Howard Koh, Harvard professor and former Assistant Secretary for Health for the US Department of Health and Human Services (HHS)—also served as a call to action for public health professionals to apply an ethical framework that upholds values such as health equity, interdependence, transparency, and justice when engaging in decisions that impact the public. But why is this approach necessary? According to Krieger, it is an important lever for social change. She notes,
Understanding ethics…is what allows you to contest scientific racism. It’s what allows you to contest scientific sexism. It is what allows you to look deeply at the assumptions. [Ethical] theories are powerful tools; they are intellectual tools that guide how we think. They guide how we reason; they guide how we test our ideas.
Indeed, the public health field is no stranger to the impacts of scientific racism, which is entrenched in many of today’s systems and practices, further underscoring the need for a shared analysis when making population-based decisions. In her opening comments, Krieger notes, “We have to pay attention to the ethics of our profession, knowing also that our profession at times has acted very unethically…when public health, for example, embraced eugenics.
Krieger—along with many others leading antiracism efforts across a variety of disciplines—notes the importance of naming systemic racism. In her address, she illustrates how ethics can be a useful tool with which to understand how people in society relate to institutional and political power. Krieger explains,
One key ethical consideration is always thinking about who’s benefitting from harming others when we think about many of the key obstacles that impede our ability to have health equity and health justice. You [must] think about people…who are making policies; [who are] holding on to power, [who are not allowing for equity to exist…that has to be named upfront, and to me that is the fundamental ethical duty in public health.
Public health has identified and focused much of its energy on addressing the social factors that influence health—termed social determinants. Yet, according to Krieger, the social relationships and interactions within these domains warrant a keen focus when exploring ways to remove obstacles to equity. She says, “Social determinants are not things. Social determinants arise out of the societal relationships of power and particularly power and property.”
So, how does one use ethical theory to explore social relationships to power and incorporate an ethical lens into decision-making in a systematic way? According to Dr. Warren, “The intention to do good is very different than doing good.” He further explains that ethical decision-making requires not only an eye toward social justice, but authentic community engagement, beneficence—in addition to benevolence—and the capacity “to measurably do good beyond your intentions.” To achieve this, it is “critically important to have a language that we can agree upon and we can operationalize.Warren notes that as a profession, “Decision-making involves determining a framework so that we (public health practitioners) can decide together what is the best thing to do.”
Understanding the importance of a shared framework, APHA convened a multidisciplinary group to develop the public health code of ethics—a guidebook that outlines a set of professional standards and expectations intended for public health practitioners. The code of ethics describes six core values (trust, health and safety, health justice, interdependence and solidarity, human rights, inclusivity and engagement), along with a framework and detailed guidance on considerations for public health decision-making.
Public Health Ethics: A Shared Language and Approach
To ground participants in shared language, Lee explains in her opening presentation that public health ethics is both a noun and verb.
It is the moral governance of public health, the constellation of values that motivate our work, things like equity, respect for human rights, common good, solidarity, and justice. Public health values recognize that we share this planet with eight billion other people…and this means that we consider many different values, not just the few I just mentioned. We recognize that while there are many common things that all of us likely value, there are differences in how we define living our best lives, and because public health is public, we [must] acknowledge and make room for these differences.
Public health ethics is also a verb. It is something we do. It’s a way of reasoning through ethically challenging situations, or the application of a decision-making framework that helps us decide or determine a course of action when values conflict or when there is tension between two or more things that we care about. Often, our choices are not a simple right versus wrong.
These ethical values and approaches can be applied to all aspects of decision-making. With the goal of promoting the health of all individuals, the panelists highlighted examples of how an ethical lens can be incorporated into federal and local decisions about data collection, housing, COVID-19, and much more.
There is also a need to overhaul public health’s data infrastructure. Krieger points toward the need for improved systems, an issue that impacts all areas of public health. In her commentary, she notes the importance of applying an ethical lens when considering federal budget allocations to build infrastructure that would enable the tracking, analyzing, and sharing of data in a meaningful way—which impacts the public health field’s capacity to support the nation’s health. She states,
We know that [in order] to understand the health of the public and to understand the health of the people, we need to have a good data infrastructure. And data infrastructure means the people who actually collect the data; who actually record it; who actually have the equipment and the personnel to communicate it; to actually have connected capacity across this country, from local to tribal to county to state to federal—and we don’t have that.
Referencing her recent Lancet article, Krieger notes,
The three, four, or five billion per year that might be needed to fix this problem is one percent of the US military budget. More than one million people have died in this covid pandemic in the US alone, and that’s ten times more the number of military casualties since World War II. So, something is amiss here, and we can try to really emphasize what the values are and what the priorities are because it’s not again about things. It’s about decisions and people and power relations.
Supporting the case for a strong data infrastructure, Holtgrave describes how data can provide insights regarding the progress made toward shared goals and gives examples of how agencies can use data to boost accountability and civic engagement. Drawing from his experiences working with the Office of National Drug Control Policy, he notes it is important to understand:
What are those metrics that we are going to go after as a nation? What are we going to hold up? How are we going to think about health disparities and equity related to those goals as well? How do we set those metrics so that they are [publicly] available, [so] that their dashboards are on the website… and you can look and see [whether] progress being made or is it not being made. And if so, what are the additional steps that need to be taken.
The perspectives shared by the panelists are born of an urgency to address the national and global threats posed to our collective health and the health of our planet. Krieger notes,
I think that the extent [to which] we can structure our questions and see who our frameworks are making visible and invisible to the problems and visible and invisible to who is causing harms is really important. The ethical principles that have been articulated can help in doing that. Obviously, if we were in a world where everything was fine we would not be in the world that we are in now and with the severe threats of climate crisis [and] the threats of what the last 40 years of neoliberal economics have wrought, [and] the extractivism, [and] the ecological damage, [and] the damage of human relations to each other—framing of people as simple transactional relationships and not actually interdependent—has really extracted great tolls on the health of this country.
In Krieger’s closing comments, she ends with a call to action.
Health Justice means…not only looking at who should be doing better, but understanding what the relationships are, the social relationships that lead to some groups being denied resources and other groups keeping the resources that are often accumulated on grounds that are unfair and unethical. We need to keep these kinds of principles very clear and make sure we are constantly [assessing this] for any kind of public health work that we do [and] also [consider] who does that demand that we work with? Solutions are not just within public health—they never have been. But public health can stand up for the health of the people and ask who is aiding it…and [against] who is harming it.
As this work evolves, the panelists invite us to engage in and expand upon this work. As Krieger notes, ethics and “science is about public knowledge that’s publicly tested, is in the public domain, and can be contested. But if you only have a small number of people doing the science because of discrimination…you don’t really have everybody at the table who needs to be at the table to challenge the assumptions that are built into the science.” Public health will need to continue grappling with how to ensure that the ethical values of everyone served are honored and reflected in its approaches and frameworks.