1. Pestronk, Robert M. MPH
  2. Jacobson, Peter D. JD, MPH

Article Content

Ethics. We each think we have them. We hope those whose lives influence ours have them, too. But what exactly are they? On what value system are they based? On what values should they be based? Which values or value systems are best? How can we use them in a timely, appropriate, and efficacious manner? When should we use them? Authors in this special issue grapple with these and many other related questions.


We are delighted to be editors for this special issue. Its articles are, for the most part, based on presentations made at a conference we helped produce at the University of Michigan School of Public Health on March 30, 2007, with generous financial assistance from the Robert Wood Johnson Foundation and the National Association of County and City Health Officials (NACCHO). Our special thanks go to James Ransom at the NACCHO, without whom neither the conference nor the manuscripts would have been possible. Visit the NACCHO Web site to view and listen to the presentations (


Aside from the thoughtfulness and the quality of the presentations, perhaps the most important aspect of the conference was to bring together academics and practitioners to consider the difficult ethical challenges practitioners face on a daily basis and examine possible ways of resolving these challenges. From the beginning, we viewed the conference as a starting point for a longer-term dialogue about integrating ethics into routine public health practice and preparedness activities. We hope that future conferences will build on this effort to consider broader concerns such as resource allocation and the development of frameworks that practitioners can use as guides to identify and resolve difficult ethical dilemmas.


The issues discussed in the articles that follow are not new. Indeed, they are inherent in public health practice and of profound importance to those working in the public health system. In core public health activities, for example, practitioners must balance actions that protect the population's health with the need to respect individual liberties. Ethics are at least implicit, and often explicit, in our day-to-day work in which we believe that the health of a population should, on occasion, trump the rights of an individual. Something supports this belief. It is our system of public health ethics. Like law, which forms one stone in the foundation of public health practice, ethics is a second basic underpinning.


So the question of "why now" for an issue on public health ethics has several possible answers. With the rising attention to terrorism over the last decade, public health practitioners are asked to make our ethical case explicit as we consider the strategies and tactics to be used and the rationale for them to be employed in working to protect the public from danger and prevent the spread of disease and preventable death. In an era of limited and dwindling resources for local public health departments, practitioners must inevitably make wrenching choices at the margins between equally desirable programs that protect equally vulnerable populations. Making these trade-offs inevitably involves difficult ethical choices that could benefit from a workable public health ethics framework.


Beyond the practical import of using sound ethical analyses to make difficult decisions, several attributes of ethics offer value in public health practice. Fundamentally, ethics are a practical guide for structured thought and analysis. Ethics help us better understand the nature of vexing challenges and why some challenges are more vexing than others. They can help us know both what to consider and what we should ultimately know. They may prompt thought about who we should consider or who should help us reach conclusions about what the "right" choice might be when confronted by a problem that will affect life or death, a single person, or a population of people. A signal characteristic of the attention to sound ethical assessment is that it will help make more transparent and clear the reasons for the decisions we reach. With public health officials under greater scrutiny than ever, and facing the trade-offs mentioned above, transparency is imperative to retain the public's trust. In addition, the use of ethics in decision making is an implicit recognition of individual and population diversity. If we were all the same, interchangeable in any regard, we would be less concerned with the outcomes of our decisions because how they affected others would be a less meaningful consideration.


It comes as no surprise to us that there is academic interest in ethics; after all, how ripe an area for inquiry and exposition, how ancient and timeless an area of thought!! How diverse the ethical platforms on which decisions have been made over time and therefore how fertile an area for study, consideration, and reconsideration. Yet, despite years of academic attention to bioethics, the field of public health ethics is at a nascent stage. Great academic interest in public health ethics is, in part, a function of the maturation of bioethics. In the field of bioethics, though, the ethical principle of autonomy has monopolized the discussion. In contrast, public health ethics forces academics to develop new frameworks and terms to integrate both the individual and the population ethical concerns into a coherent analysis.


Equally important, academic researchers need to move beyond the purely conceptual as they begin to examine public health ethics. Developing sound theory and conceptual frameworks is necessary but not sufficient. To avoid the sterility of current bioethics, it is important for academics to test their theories empirically. Otherwise, public health practitioners will derive little benefit from the academic interest. It is also important for academics to begin developing with their practice colleagues ethical analyses using multiple frameworks, which can be referenced by practitioners as they grapple with day-to-day and extraordinary challenges. These might be in the form of logical prose or, perhaps, in sets of questions or checklists. We use after-action reports in preparedness work to document what went as planned and what actions need redesign and refinement to work well the next time. Practitioners who use these analytic frameworks might develop similar after-action reports. These reports might begin to help other practitioners (and academics) understand how these analyses are of practical use. Web 2.0 technologies might be employed to rapidly share insights among practitioners.


An issue on ethics is timely now, too, as we rethink the nature and content of our work. As in many other areas of public health practice, here, too, we are reexamining the roots of practice. What better time to do so than with the "graying" of the public health workforce? As power, prestige, and positions are transferred to a new generation of leaders, they should become familiar not just with the scientific and practical aspects of public health work but also with the various ways in which this work may or must be justified. New minds may consider which of this work or current strategies should no longer be employed or which new ways of doing business may be "better."


As noted earlier, we viewed this conference as a beginning of a promising new dialogue between academics and practitioners. It is important that the conference be followed with a series of specific activities to build on the conference's success. First, there needs to be a venue for ongoing dialogue between academics and practitioners. As the next step, we suggest a similar conference among practitioners and academics to develop a research agenda devoted to identifying and resolving the day-to-day ethical challenges practitioners face. For example, academics might develop and empirically test competing decision-making frameworks to determine which framework is most effective.


Second, NACCHO and other national organizations can serve as a clearinghouse to develop a database of specific public health ethical challenges confronted and how they are resolved. Third, engaging the community to determine how they view public health ethics is essential if local health departments are to retain public legitimacy. Finally, we encourage readers to engage the authors in examining the issues and suggesting new and creative ways of improving ethical decision making among public health practitioners.