1. Thomas, James C. MPH, PhD

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Six years ago, the American Public Health Association adopted a code of ethics.1 Not exactly scintillating news. But it marked a watershed in the practice of public health. Until that time public health had borrowed its ethics from medicine, with its 4 principles of autonomy, beneficence, nonmaleficence, and justice. These principles have served medicine well but the situation from which these principles arose, namely the interactions between a patient and a care provider, differ from the situation that gives rise to ethical quandaries in public health-interactions between a government agency and a population. Thus, for example, in the context of a population where one person's infection is another person's exposure, sometimes the autonomy of the infected person needs to be held in check for the benefit of others. For this reason, the principle of interdependence stands out more prominently in public health ethics than in medical ethics.


Why the Late Arrival of Public Health Ethics?

Public health ethics has distinguished itself from medical ethics only recently in part because physicians have long been seen as the keepers of all things related to health. A few examples from my own career illustrate this. (1) In the early 1980s, when I was finishing my PhD in epidemiology, I was discouraged from applying to the Centers for Disease Control and Prevention's (CDC's) Epidemic Intelligence Service because I was not a physician. The same is not true for today's school of public health graduates. A number of my former students without a medical degree have gone on to work with the Epidemic Intelligence Service. (2) In 1989 I left my job as an epidemiologist at the Los Angeles County Health Department in large part because, not being a physician, I had no opportunities for advancement. (3) When I began working in the Department of Epidemiology at the University of North Carolina School of Public Health, most of my fellow professors were physicians. Physicians are now a small minority among our faculty.


When public health was predominantly a medical domain, medical ethics were assumed to address the ethical concerns. It was perhaps the advent of AIDS in 1981 that opened the door for more nonphysicians into public health. The disease was so complicated and cures so evasive that the world turned to people with expertise in behavioral research, health economics, and policy analysis to address the epidemic. Moreover, because the epidemic first presented itself in the United States among a group of socially stigmatized people, laws governing confidentiality, isolation, and the distribution of resources were brought into question.2 Thus, lawyers were among the first to raise issues specific to public health that had an ethical tone.


People with legal training remain prominent in discussions of public health ethics. The need for their expertise is indisputable, yet the lawyers I know who address public health ethics are quick to point out that they are not ethicists. Ethical thinking and training is different from legal thinking and training. Given a particular situation, a lawyer usually runs quickly to questions of what the law will allow, whereas an ethicist will consider the right thing to do regardless of what the law says. In other words, an ethicist considers what the law should allow or prohibit.


Academic ethicists, on the other hand, are notorious for avoiding concrete or prescriptive answers. Moreover, they are too seldom involved in the situations that give rise to the ethical concerns. So, for example, very few academic ethicists have worked in a county or state health department. If they had, they would know that public health practitioners are imminently practical. They need to know what to do right now, and they need to know the action is both effective and equitable.


The Turning of the Tide

Some of the delay in the emergence of public health ethics, then, was a lack of nonmedical public health practitioners who were versed in ethics. That gap was addressed in part when the Public Health Leadership Society convened a coalition of public health practitioners (some of them medically trained, some of them not), academic and medical ethicists, and public health lawyers to write a public health code of ethics.


Perhaps as important as the code was the clarification of the values and beliefs in public health that underlie the code and are included in its documentation. Thus, the writing of the code was an exercise in values clarification, which in turn, shed light on the mission of public health. The adoption of the code by national organizations such as NACCHO is a further indication that the values built into the code are widely recognized as truly reflecting the heart of public health.


Efforts to disseminate the code and the perspective it brings have included the following: (1) the identification of competencies and skills necessary for the ethical practice of public health.3 This list of skills was used by the Association of Schools of Public Health in the creation of the MPH core competencies4 and by the National Board of Public Health Examiners for certification in public health5; (2) a set of on-line modules in public health ethics.6 These free access modules have been used for training participants in several Public Health Leadership Institutes; (3) applications of the Code to contemporary public health topics, such as genomics and pandemic influenza.7,8 As mentioned elsewhere in this issue, Bernheim and Melnick are actively engaged in accumulating case studies to illustrate uses of the Code9; and (4) the Centers for Disease Control and Prevention established an Ethics Subcommittee of the Advisory Committee to the Director.10 The Ethics Subcommittee is working closely with a new cadre of CDC employees identifying and addressing ethical issues in each of the Centers. The Public Health Code of Ethics plays a prominent role in the process.


Where We Need to Go From Here

Of course, there also has been progress in public health ethics apart from the code. For example, Jennings and colleagues produced a model curriculum in public health ethics.11 Moreover, a number of books have been recently published.12-14 Still, public health ethics remains a young field. Although an awareness of public health ethics and its related skills have established a foothold in some academic settings and among the leaders of national public health organizations, most students and practitioners of public health remain unaware of and untrained in ethics. This state of affairs was underscored by a number of the presentations in the NACCHO-sponsored workshop on ethics reported in this issue. Based on the workshop presentations and my own knowledge of the state of public health ethics, I suggest the following as next steps for furthering the ethical practice of public health.


Raise up experts

We need more public health practitioners with formal graduate training in ethics. Although the slowly growing number of ethics faculty positions in schools of public health is a welcome development, they are seldom filled by people who have had experience in a health department, much less who continue to work in a public health practice setting. In contrast, many medical ethicists are trained in medicine and some continue to practice medicine while also studying and teaching ethics. For there to be scholars with one foot in public health practice and another in ethics, academic leaders will have to overcome their bias against practitioners and a few practitioners (who are typically action-oriented) will have to overcome their bias against academics (which is typically action-averse).


Do the homework

There are a few articles and books on unethical events in the history of public health, but the topic remains relatively unexplored. Not infrequently, stories of the past reveal human or institutional tendencies that we need to correct or restrain in the present and future. In addition, there are some ethical questions that need to be addressed with empirical research. For example, what are the best ways to gather input from a community when planning a public health policy?


Disseminate skills

We are all born or enculturated with a sense of right and wrong. This intuition gives us a leg up in thinking about ethics, but it can also make us regard training in ethics as unnecessary. As anyone who has created or implemented policies for a community knows, treating the variety of interest groups equitably can be an immensely difficult challenge. Others who have walked this road before have developed principles and tools, but one needs to actually study and practice them in order to apply them well. We must ensure that each practitioner of public health is trained in the ethics skills relevant to his or her responsibilities.


Integrate into the workplace

We are most likely to act ethically when ethics is woven into the fabric of our lives and work. We are least likely to act ethically when we have to stop what we were doing and pick up a new task that feels like busy-work or a barrier to accomplishing our purpose. The ethics practices that are now part of public health research are criticized by some as too often having such a feel. Ideally, we would practice public health more ethically by incorporating ethical steps and considerations in our existing policies and processes rather than creating a separate bureaucracy. I hold out hope that people will actually look forward to ethical decision-making in the practice of public health because it gives them an opportunity to interact with others over topics they care about deeply.


Keep the main goal in mind

Choosing among several options for action-each of them flawed-can lead to paralysis. One goal important to remember is that we are not looking for the "right" answer but one that is morally defensible. When we make a tough decision, are we able to say with sound ethical reasoning why we made the decision we did? It is also important to remember that our goal is not an ethics bureaucracy or even an ethics scholarship. Our goal is health with justice and justice through health. Our deliberations on ethics are worth nothing if they do not move us toward this goal.




1. Thomas JC, Sage M, Dillenberg J, Guillory VJ. A code of ethics for public health. Am J Public Health. 2002;92:1057-1059. [Context Link]


2. Gostin LO, The limits of compulsion in controlling AIDS. Hastings Cent Rep. December 1986:24-29. [Context Link]


3. Thomas JC. Skills in the ethical practice of public health. J Public Health Manag Pract. 2005;11:260-261. [Context Link]


4. Association of Schools of Public Health. Master of public health core competencies. Accessed May 6, 2008. [Context Link]


5. National Board of Public Health Examiners. Certification exam. Accessed May 6, 2008. [Context Link]


6. University of North Carolina. Public health ethics online modules. Accessed May 6, 2008. [Context Link]


7. Thomas JC, Zuiker E, Millikan R, Rockhill B. Genomics and public health ethics. Am J Public Health. 2005;95:2139-2143. [Context Link]


8. Thomas JC, Desgupta N, Martinot A. Ethics in a pandemic: a survey of the state pandemic influenza plans. Am J Public Health. 2007;97(suppl 1):S26-S23. [Context Link]


9. Melnick A, Bernheim, R. Principled Leadership in Public Health: Integrating Ethics Into Practice and Management. J Public Health Manag Pract. 2008;14(4):358-364. [Context Link]


10. Centers for Disease Control and Prevention. Office of the Director, Science Coordination and Innovation, Public Health Ethics. Accessed May 6, 2008. [Context Link]


11. Jennings B, Kahn J, Mastroianni A, Parker LS. Ethics and Public Health: A Model Curriculum. Association of Schools of Public Health; 2003. Accessed May 6, 2008. [Context Link]


12. Anand S, Peter F, Sen A, eds. Public Health, Ethics, and Equity. New York: Oxford University Press; 2006. [Context Link]


13. Bayer R, Gostin LO, Jennings B, Steinbock B, eds. Public Health Ethics: Theory, Policy, and Practice. New York: Oxford University Press; 2006. [Context Link]


14. Powers M, Faden R. Social Justice: The Moral Foundations of Public Health Policy. New York: Oxford University Press; 2006. [Context Link]