Stanford Encyclopaedia Ph Ethics

7/26/2019 Stanford Encyclopaedia Ph Ethics

1/29

STANFORD ENCYCLOPAEDIA.

Public Health Ethics

First published Mon Apr 12, 2010

At its core, public health is concerned with promoting and protecting the health ofpopulations, broadly understood. For example, the Institute of Medicine defines

public health as what we, as a society, do collectively to assure the conditions inwhich people can be healthy I!M "#$$%. !ften, but not exclusively, collective

interventions in service of population health involve or re&uire government action.In the 'nited (tates, for example, the )enters for *isease )ontrol and +revention,

the Food and *rug Administration, the nvironmental +rotection Agency and the)onsumer +rotection Agency are in part or in whole public health agencies. All

states and most municipalities or counties have health departments whose variousfunctions include everything from the inspection of commercial food service to the

collection and use of epidemiological data for population surveillance of disease.)ollective action to promote and protect population health also occurs at the global

level, as exemplified by the activities of the -orld ealth !rgani/ation.

!ne view of public health ethics regards the moral foundation of public health as

an in0unction to maximi/e welfare, and therefore health as a component of welfare+owers 1 Faden 2334%. 5his view frames the core moral challenge of public

health as balancing individual liberties with the advancement of good health

outcomes. )onsider, for example, how liberties are treated in government policiesthat fluoridate municipal drin6ing water or compel people with active, infectioustuberculosis to be treated.

An alternative view of public health ethics characteri/es the fundamentalproblematic of public health ethics differently7 what lies at the moral foundation of

public health is social 0ustice. -hile balancing individuals8 liberties with promotingsocial goods is one area of concern, it is embedded within a broader commitment

to secure a sufficient level of health for all and to narrow un0ust ine&ualities+owers 1 Faden, 2334%.9":5hus, another important area of concern is the

balancing of this commitment with the in0unction to maximi/e good aggregate orcollective health outcomes. 'nderstood this way, public health ethics has deep

moral connections to broader &uestions of social 0ustice, poverty, and systematicdisadvantage.

-ithin this general framewor6, this paper proceeds as follows7 (ection " lays outsome of the distinctive challenges of public health ethics. (ection 2 discusses

different 0ustifications for public health interventions, including the role ofpaternalism, its various interpretations and how these bear on the permissibility of

public health interventions. Also discussed in (ection 2 are broader &uestions ofdemocratic legitimacy. (ection ; focuses on &uestions of 0ustice and fairness in
http://plato.stanford.edu/entries/publichealth-ethics/notes.html#1http://plato.stanford.edu/entries/publichealth-ethics/notes.html#1http://plato.stanford.edu/entries/publichealth-ethics/notes.html#1


2/29

public health ethics. Finally, (ection < surveys six broad areas of global 0usticeconcern that deserve further attention from a public health ethics point of view.

!verall, this entry strives to provide a general lay of the land with regards to thecentral issues that drive public health ethics, as well as a more in=depth discussion

of 0ustice, fairness, and priority setting in public health.

". *istinctive )hallenges of +ublic ealth thics

2. >ustifying +ublic ealth +rograms and +olicies

o 2." !verall ?enefit

o 2.2 )ollective Action@fficiency

o 2.; )ommunitarianism

o 2.< Fairness in the *istribution of ?urdens

o 2. 5he arm +rinciple

o 2.4 +aternalism

o 2.B Ciberty=limiting )ontinua and A )entral 5as6 of +ublic ealth

thics

;. >ustice and Fairness in +ublic ealth

ustice

o


3/29

Eelated ntries

1. Distinctive Challenges ! Public Health Ethics

5here is no standard way of organi/ing the ethics of clinical practice, public health

and biomedical science. Although these distinctive concerns are often capturedunder the umbrella term of bioethics, sometimes bioethics is presented as the

e&uivalent of medical ethics or in contrast to public health or population=levelbioethics. -hichever approach is preferred, a 6ey &uestion remains7 what

distinguishes public health ethics from medical ethics 5he answer lies in thedistinctive nature of public health. +ublic health has four characteristics that

provide much of the sub0ect matter for public health ethics7 "% it is a public or

collective goodG 2% its promotion involves a particular focus on preventionG ;% itspromotion often entails government actionG and


4/29

+ublic health8s commitment to prevention carries with it particular moralchallenges. liminating or mitigating a harm that already exists can be viewed as

being of greater moral importance than preventing that harm from materiali/ing.Insofar as this view is incorporated into health policy, public health interventions

that focus on prevention can receive less funding and public support than medicaltreatments. For example, both policy ma6ers and the public tend to place a higher

priority on ensuring that heart patients have access to surgery and medications thanon programs to prevent heart disease through diet and exercise. Moreover, although

the costs and burdens of preventive interventions occur largely in the present, thebenefits of successful preventive interventions occur in the future, and usually only

to some members of the population whose identities cannot be predicted inadvance and whose numbers can only be estimated probabilistically. 5hus,

prevention policies and programs raise &uestions about how we should thin6 aboutstatistical and unidentified lives and persons, and whether health gains in the future

should be treated as worth less than health gains in the present. In some cases, thebeneficiaries of prevention interventions are members of future generations,complicating the moral picture even further.

5hird, as noted previously, achieving good public health results fre&uently re&uires

government action7 many public health measures are coercive or are otherwisebac6ed by the force of law. +ublic health is focused on regulation and public

policy, and relies less often on individual actions and services. In this as in all otherareas of official state action, we therefore have to address tensions among 0ustice,security, and the scope of legal restrictions and regulations. 5his adds to the

peculiarity of the 0ustificatory &uestions surrounding public health7 the exercise ofpublic authority and the imposition of public sanctions and penalties in an area as

deeply personal as an individual8s health choices re&uire strong 0ustification. 5hesame &uestions of trade=off between personal freedom and collective action that

arise in the political arena thus arise for public health. It is in this context thatconcerns about paternalism typically emerge.

Fourth, public health has a definite conse&uentialist orientation. +romoting public

health means see6ing to advance good health outcomes and, usually more

pressingly, to avoid bad health outcomes. As noted at the outset of this essay, insome discussions of public health ethics, this outcome=orientation is viewed as the

moral 0ustification and foundation of public health and, as with all conse&uentialistschemes, is presented as needing to be constrained by attention to deontological

concerns such as rights, and by attention to 0ustice=related concerns such as the fairdistribution of burdens )hildress et al. 2332G Hass 233"% . -hile public health

ethics has to engage with the traditional problems raised by its conse&uentialistcommitments, for those who view social 0ustice as the moral foundation of public

health, considerations of 0ustice provide the frame within which the moralimplications of public health8s conse&uentialist orientation are addressed.


5/29

5hese four distinctive features provide public health ethics with its basic structureand orientation. 'nder the first rubric, important &uestions arise with regard to the

scope of public health7 who is the public 5he usual assumption is that the publicis a discrete unit that corresponds with state boundaries7 one single country8s

population. ?ut in a global world, that assumption is not always plausible for avariety of reasons. )ommunicable diseases have a way of ignoring state

boundaries, and prevention measures in one country may be futile if othercountries do not follow suit. Moreover, the statist focus is not always readily

0ustifiable7 insofar as diseases cross borders, should public health interventions dothe same Further &uestions about 0ustice and e&uity across borders also arise7 do

wealthier countries have obligations to attend to the public health of less fortunateothers 5hese issues, as well as &uestions of priority setting in public health, will

be discussed further in section I below.

*epending on the particular health challenge we are concerned with, the public in&uestion can be more local or more global than a single country8s population.

Jational boundaries are relevant because policies and regulations are usually set by

individual countries, and vary from country to country. 5hey are also relevant forreasons having to do with government control7 countries report their data about

communicable disease outbrea6s, burden of disease, and other health indicators toglobal institutions such as the -orld ealth !rgani/ation -!% on a voluntary

basis. Although International ealth Eegulations to which "#< countries aresignatories provide an international structure for global public health, as with muchinternational law and regulation, enforcement mechanisms are wea6. It is not clear

what the moral implications of these practical limitations should be for publichealth. 5he structure of the problem is similar to environmental challenges such as

air pollution and global warming7 determinants of ill health are not restricted bynational boundaries, and we are all ultimately connected to each other8s health

status, at least in some ways. ?ut more importantly, citi/ens in the developed worldare arguably causally connected to some health deprivations in the developing

world, for example by upholding restrictions on the production and distribution ofgenerics that hinder the containment of easily treatable diseases in poor countries

+ogge 2332%. 5his gives public health, and therefore public health ethics, a uni&ue

and very interesting location vis=K=vis discussions of global 0ustice, our duties tothe distant poor, and the need for global cooperation to address common problemsolland 233B%.

Another issue that comes up in this connection is the following7 are public andpopulation interchangeable terms to designate the entity whose health we are

concerned with Is there a significant conceptual difference, a difference in moralvalence, or a difference in attitude and orientation between public health ethics on

the one hand, and population=level health ethics on the other 5he literaturepresents three general ways of denoting the ob0ect of public health7 community, the

public, and populations. In one sense, the most morally laden manner ofdesignating those who are sub0ect to, and benefit from, public health measures, is


6/29

to thin6 about them as a community ?eauchamp 1 (teinboc6 "###%. Eeference tocommunity implies a uniform group, usually with a shared language, culture,

history, and geographical location. )haracteri/ing the concern of public health asbeing the health of the community renders more natural and possibly more

plausible% appeal to the common good as a way of 0ustifying public healthinterventions. Eeference to the public shares some of those same features but

tends to be less morally laden. 5his is in part because the public is somewhatmore anonymous than the community and does not necessarily signal a tight

cultural connection. Eather, it connotes a relatively discrete unit with somecommon institutions and usually a shared political life. 5hus, references to the

public as well as to the community may encourage the perception that the good weare see6ing to advance is that of a geographically bounded unit, with community

connoting stronger cultural associations, and public connoting some 6ind ofofficial political unit such as a state or a country.

)haracteri/ing the health we are trying to advance as that of populations, bycontrast, may minimi/e the implication that special shared features or

characteristics are needed in order for a group of individuals to constitute acollective unit whose health can be of concern. ?ecause of that, it may lend itself

more readily to an internationalist, less inward=loo6ing orientation7 any population,regardless of nationality or geographic location, has health interests that ought to

be attended to and advanced -i6ler 1 ?roc6 233B%. +opulations can be morelocal or more global than a community or the public. 5his way of spea6ing alsomay dilute the emphasis on national borders as a way of delineating the scope of

concern, and provides more flexibility in the ob0ect of concern for public health. Inmuch the same way, discussion of global health, as opposed to international health,

is seen as helpful in emphasi/ing a focus on the health needs of all, as opposed to afocus on international cooperation and the health needs of peoples in countries

other than one8s own.

5his is not, of course, to say that those who prefer the term public health topopulation health do not share a global orientation. Indeed, the -orld ealth

!rgani/ation is generally referred to as a global public health institution, and those

who wor6 to promote health transnationally are referred to as public health and notpopulation health professionals. Indeed, although some see a substantive

conceptual divergence in ways of thin6ing about whose health is to be protectedand promoted, others see no conflict, at least between the concepts of public health

and population health. For example, the Juffield )ouncil on ?ioethics uses theterm population health to refer to the collective state of health of members of a

population and the term public health to refer to efforts made to improve thepolitical, regulatory and economic environments that affect prospects for health. (o

understood, the ob0ect of public health is the improvement of population healthJuffield )ouncil on ?ioethics 233B, p. L%.


7/29

Another conceptual challenge central to public health ethics is how to thin6 aboutpublic health or population health as a public good. Is the health of the public or of

a population a good in its own right, or can it meaningfully be understood only asan aggregation of the welfare interests secured for each individual that comprises

the population Is public health a good that nations and global institutions canrightly see6 with the same 0ustificatory structures and limitations with which they

see6 national security and world peace, or is it somehow a more limited ordifferent 6ind of political construct

)ommon to the second, third and fourth features of public health is the &uestion ofhow broadly or narrowly to understand what public health entails +owers 1 Faden

2334%. Diven a widening understanding of health and the factors affectingprospects for population health, public health can be viewed as being so expansive

as to have no meaningful institutional, disciplinary or social boundaries.

verything from crime, war and natural disastersG to population genetics,environmental ha/ards, mar6eting and other corporate practicesG to politicaloppression, income ine&uality and individual behavior has been claimed under the

rubric of public health. +art of what ma6es each of these diverse things of concernis their impact on health, and in that sense they are all public health problems. A

central role of public health, grounded in social 0ustice, is to bring attention to allaspects of the social or natural world that exert a significant impact on the

preservation or promotion of health, and not only those that can be effectedthrough traditional public health measures or means.

At the same time, however, health is only one dimension of human well=being.)alling attention to the devastating impact on the health of women of 5aliban rule

is important, but it should not be confused with reducing the in0ustices of theoppression of women to its health effects. 5he assault of such oppression on

personal security, self=determination and respect is of independent moral concern.(imilarly, while reducing violence is critical to population health, that does not

mean that law enforcement, the criminal 0ustice system, diplomacy andinternational relations should be considered tools of public health. ?ecause so

many of the determinants of the different dimensions of well=being overlap and

reinforce one another, it is not surprising that different social institutions andprofessional communities share common concerns and priorities, nor should it be

expected that public policies rest on only one moral consideration li6e health orsecurity.

5he flip side of this observation is that public health has an obligation to evaluate

the impact of its policies and practices on human well=being broadly, and not onlyon health. Duaranteed access to basic health services can improve health, but 0ust

as importantly, it can provide people with a sense of social worth and eliminate theinsecurity of being unable to provide for loved ones in times of crisis. (imilarly,

screening programs for sexually transmitted infections may improve health but,depending on features of the programs and the contexts in which they are


8/29

implemented, they may result in social disrespect, decreased personal security andconstraints on personal behavior.

5he overlapping of effects and 0ustifications is particularly clear in prevention.Immuni/ation, water fluoridation, anti=smo6ing campaigns and motorcycle helmet

laws are all paradigmatic preventive public health interventions. At the same time,however, interventions generally outside the purview of public health institutions

and professionals such as early childhood education, income supports, literacyinitiatives for girls and safe housing programs all can be effective in preventing

illness and in0ury. In some cases, such interventions may be more effective andefficient in achieving health gains than paradigmatic public health programs.

Morally responsible public health policy re&uires attentiveness to the multipledeterminants of health. 5his re&uirement does not signal that public health has no

boundaries. Eather, public health has a uni&ue relationship of stewardship to one

dimension of well=being, health, and to the particular determinants that have aspecial strategic significance for health. (ome of those determinants are the classicfocus of public health such as infectious disease control and the securing of safe

food, water, and essential medications. owever, exercising that stewardshipre&uires responsiveness to the best available evidence about all the determinants,

across the landscape of an interconnected social structure, that have a specialstrategic relation to health, including those outside the conventional remits of

public health agencies and authorities. +olicies governing education, foreignassistance, agriculture, and the environment can all have significant impact onhealth, 0ust as health policies can have impact on international relations and

national and global economies. +roviding public health arguments in defense ofparticular environmental or educational policies, and recogni/ing that such policies

can have profound effects on health, simply recogni/es the complex interweavingof the multiple dimensions of human welfare.

!ne worry raised by this interconnectedness across spheres of social life and policy

is that classifying something as a public health matter could be an effective way ofta6ing it out of the realm of legitimate discussion. If the goal of protecting health is

seen as clearly good, government actions aimed at securing health may be less

scrutini/ed than actions aimed at more controversial ends, leaving public healthofficials with too much power and too little democratic accountability. As a

practical matter, however, these concerns may not be realistic. Although data onthis point are hard to come by, it is li6ely that the reverse is true7 public health

agencies and wor6ers are more li6ely to have insufficient political power, authorityand resources at their disposal to achieve important and pressing goals than to

wield too much. It is not usually individuals8 civil rights to which public healthinterventions stand in opposition, but rather private, corporate economic interests

such as the tobacco industry, the meat and dairy industry, and so on. Jonetheless, itis worth raising these worries at least to 6eep them in view as a possible issue for

public health ethics to address.


9/29

ven if the worry that expanding the classification of something as a public healthmatter in some way threatens civil liberties is nothing more than fear=mongering,

the breadth of what falls under public health may raise concerns about democraticlegitimacy. Insofar as health authorities have a public mandate to advance health, is

it therefore appropriate for them to hue to strict guidelines as to what they canunderta6e in the name of public health based, at least in part, on the expressed or

revealed preferences or values of those within their reach 'nder what conditionsare measures such as public health surveillance and the banning of certain food

materials properly considered to be overreaching by public health authorities, andtherefore to constitute a lac6 of adherence to their democratically=given mandate

+ublic health ethics has to give serious consideration to the &uestion7 how exactlyshould the mandate of public health authorities be specified such that they do not

run afoul of the re&uirements of legitimacy in a democratic political system

+articularly when government institutions are charged with promoting populationhealth, a tas6 of public health ethics is determining self=imposed limitations andrestrictions on what can reasonably come under the auspices of public health

authorities, for reasons having to do with concerns about individual liberty, aboutprivacy and paternalism, about democratic process, and about the place of health in

relation to other aspects of human well=being. 5hus, public health ethics also has toengage more traditional philosophical &uestions about the scope of privacy, the

reach of public policy, and the limits and legitimacy of government intervention forthe public good. 5hese issues are addressed next, in (ection 2. Moreover, scarcityand priority setting always loom large in the context of public health, giving rise to

a number of e&uity, 0ustice, and fairness concerns. As already noted, these issuesare especially acute with regard to global health. )oncerns about 0ustice and

priority setting will be addressed in greater detail in (ection ;.

". #usti!$ing Public Health P%g%a&s an' Plicies

+ublic health draws its foundational legitimacy from the essential and direct rolethat health plays in human flourishing, whether that role is understood ultimately in

terms of maximi/ing health or promoting health in the context of advancing social

0ustice. 5his general 0ustification is sometimes too broad, however, to providesufficient moral warrant for specific public health policies and institutions,especially when, as is so often the case, these policies and institutions are

implemented by the state and affect the liberty or privacy of corporate or individualpersons. 5his section puts forward six 0ustifications or reasons that can be put

forward to defend a particular public health institution or policy.

5wo observations are worth ma6ing at the outset. First, public health policies are

rarely defended by only one reason. 'sually a mixed set of 0ustifications canplausibly be provided. For example, tax policies intended to decrease cigarette

consumption can be defended both by appeal to paternalism and by appeal toreducing the harms of second hand smo6e to children in the home and in


10/29

automobiles. (econd, the impact of public health policies is often not uniformacross all the individuals affected by the policy, and thus different 0ustifications are

sometimes put forward specific to these different people. 5his complexity isunavoidable, since it results from the nature of public health7 5he focus of public

health is population health, but populations are rarely internally uniform withregard to all features that are morally relevant to any particular policy. (ome

people may stand to benefit from the policy while others may not. Moreover, inline with concerns about democratic legitimacy and state over=reaching, some

members of the population may support the aims of the policy while others mayob0ect. For example, a ban on trans=fats in restaurants in Jew or6 and other

municipalities has been defended as consonant with the values and preferences ofmost Jew or6ers who allegedly are happy for this assistance with healthy eatingG

others, however, find the policy an unacceptable intrusion by government in whatshould be a matter of personal preference Mello 233#%.

5he first four of the 0ustifications for public health policies= overall benefit,collective efficiency@action, communitarianism, and fairness= spea6 specifically to

the context in which some members of the affected population are not directlybenefited by the policy or ob0ect to it. 5he next two 0ustifications appeal to the

significance of harm, both to others and to oneself. 5hey apply more specifically totraditional concerns about balancing respect for liberty with advancing health and

are more prevalent in the public health ethics literature than the previous four. Inthe fifth 0ustification, the argument is from a relatively uncontroversial Millianharm principle, and in the sixth 0ustification, from somewhat more tendentious

paternalistic principles.

*epending on the specifics of the public health policy, any number of these0ustifications may be applicable, and they are generally used to best effect in

combination. (ection 2 closes with a loo6 at the limits of framewor6s that focusdisproportionately on liberty considerations of the sort addressed in 0ustifications

N and N4 and on the importance of considering the range of possible moral0ustifications in analy/ing public health policies.

".1 Ove%all (ene!it

'ltimately, we all benefit from having public health interventions, and from having

trusted regulatory agencies such as the )enters for *isease )ontrol and +revention)*)% or the Food and *rug Administration F*A% ma6e decisions about such

interventions and their reach. All things considered, having public health regulationis better than not having it. aving public health decisions made on the basis of

overall statistics and demographic trends is ultimately better for each one of us,even if particular interventions may not directly benefit some of us. 5hus, the tas6

of public health ethics is not necessarily to 0ustify each particular intervention

directly. Eather, public health interventions in general, as long as they stay withincertain pre=established parameters, can be 0ustified in the same way a mar6et


11/29

economy, the institution of private property, or other similarly broad and usefulconventions that involve some coercive action but also enable individuals to access

greater benefits can be 0ustified7 when properly regulated and managed, itsexistence is by and large better than its absence for everyone. (o structured, the

0ustification for particular public health interventions, re&uirements, or restrictionsis derivative of or parasitic on a higher level 0ustification. 92:5his argumentative

strategy has a lot of appeal, particularly as a way of 0ustifying the existence ofregulatory government agencies such as the F*A. owever, it is ultimately

insufficient on its own and needs to be supplemented by other 6inds of ethicalarguments, since it does not provide the basis for the parameters themselves, or for

ethical oversight or scrutiny with regards to particular decisions such agenciesta6e9;:.

"." Cllective Actin)E!!icienc$

A related 0ustification views health as a public good the pursuit of which is not

possible without ground rules for coordinated action and near=universalparticipation. 5hus, public health is viewed as having the structure of a

coordination or collective efficiency problem. If one person or at least, a sufficientnumber of such persons% decides to go when the traffic light is red and stop when

the traffic light is green, it does not matter that everyone else is following the rules7this person will disrupt the smooth functioning of the system, with potentially

dangerous results. (imilarly, if one person or a sufficient critical mass of suchpersons% decides not to abide by a public health regulation because the regulation

does not directly benefit her or she otherwise ob0ects, the ramifications will li6elybe felt by others in her environment and beyond.9


12/29

5he collective efficiency class of arguments relies on claims about the sheernumber and technical complexity of the decisions that need to be made to protect

health in the environment and in the mar6et place, as well as the indivisiblecharacter of responses to some health threats. 5hese arguments are buttressed by

claims about the cognitive limitations and bounded rationality of individual humandecision ma6ers, and by the disproportionate political power of corporate interests

and the practices they use to manipulate and exploit our cognitive wea6nessesagainst our health interests 'bel 233#%.

".* C&&unita%ianis&

5he communitarian argument relies on the idea that what is good for the whole is

necessarily good for its parts ?eauchamp 1 (teinboc6 "###, p. B%.)ommunitarians view individuals8 identities and the meaningfulness of their lives

as indelibly tied to the well=being of their community. 5hus, on this view, publichealth interventions are good for individuals simply because they benefit the

community as a whole. 5he main appeal of this strategy is that it provides a morenurturing, less I vs. them vision of the benefits and burdens that go into

participating meaningfully in social life. It thus encourages a cooperative way ofthin6ing about public health interventions. Its main shortcoming, however, is that it

assumes too tight a connection between individuals and the communities to whichthey belong, thereby incurring the potential for abuses of less privileged

individuals within certain communities in the name of communal well=being. 9:It isunfortunately not always the case that the interests of individuals and the interests

of their communities coincide in this convenient way. Eather, such interests oftencome apart, and can come into conflict in ways that re&uire us to address yet again

the &uestions7 how much can we as6 of individuals for the sa6e of others, of whichindividuals can we as6 sacrifices for the sa6e of the community, and why 5here is

a conceptual distance between what is good for particular individuals, what is goodfor all individual members of a community, and what is good for the community.

5hus, there can sometimes be direct trade=offs between what is good for thecommunity and what is good for particular individuals within it. Jotwithstanding

these difficulties, this is certainly a strategy worth giving serious consideration as a

possible avenue for the 0ustification of public health interventions, particularly insome contexts where there is a strong sense of community solidarity.

".+ Fai%ness in the Dist%ibutin ! (u%'ens

et another appeal that can be used to defend certain public health interventionsthat impose une&ual burdens on different members of a population relies on

considerations of fairness. 5he basic premise of this line or argument would be thatburdens have to be roughly e&uivalent for everyone. 5his 0ustifies taxing different

income brac6ets at different rates. 5he same could be said for certain public health

burdens, understood as both the burdens of disease and disability and theburdens of public health interventions. ?ased on considerations such as a particular
http://plato.stanford.edu/entries/publichealth-ethics/notes.html#5http://plato.stanford.edu/entries/publichealth-ethics/notes.html#5http://plato.stanford.edu/entries/publichealth-ethics/notes.html#5http://plato.stanford.edu/entries/publichealth-ethics/notes.html#5


13/29

group8s li6elihood to contract a certain disease, and their overall health status, otherparts of the population can legitimately be as6ed to contribute, as it were, in

order to ma6e the distribution of disease burdens more e&uitable. For example, partof the rationale for re&uiring child immuni/ation prior to enrollment in school is

that this is a way to ensure that low=income children, who are generally lesshealthy than other children, have access to the needed vaccines !renstein 1

inman "###G Feudtner 1 Marcuse 233"%. +erhaps a more pertinent example is theseasonal influen/a immuni/ation policy in >apan, where children are immuni/ed

against influen/a explicitly in order to protect the elderly, for whom contractingseasonal flu is more li6ely to be fatal, and immuni/ation more li6ely to be

burdensome Eeichert et al. 233"%. et another example of public healthinterventions that appear to be guided by this 0ustification is rubella vaccination of

children for the sa6e of pregnant women and their fetuses Miller et al. "##BG A)I+"##3%. 5his reasoning can help explain why individuals are sometimes as6ed to

bear public health burdens that do not directly benefit them. owever, as with thetax case, the &uestion of how far we can go in redistributing health=related burdenswill li6ely continue to plague any proponent of this 0ustificatory strategy.

Moreover, &uestions about the plausibility of viewing health=related burdens assub0ect to distribution in this manner may also arise.

"., The Ha%& P%inci-le

It is li6ely that no classic philosophical wor6 is cited more often in the publichealth ethics literature than >ohn (tuart Mill8s essay !n Ciberty Mill "$4#%. In

that essay, Mill defends what has come to be called the harm principle, in whichthe only 0ustification for interfering with the liberty of an individual, against her

will, is to prevent harm to others. 5he harm principle is relied upon to 0ustifyvarious infectious disease control interventions including &uarantine, isolation, and

compulsory treatment. In liberal democracies, the harm principle is often viewed asthe most compelling 0ustification for public health policies that interfere with

individual liberty. For example, a prominent view in the 'nited (tates is that it wasnot until the public became persuaded of the harmful effects of second hand

smo6e that the first significant intrusion into smo6ing practicesOthe banning of

smo6ing in public placesObecame politically possible. +erhaps because of theprinciple8s broad persuasiveness, it is not uncommon to see appeals made aboutharm to others in less than obvious contexts. *efenders of compulsory motorcycle

helmet laws, for example, argued that the serious head in0uries sustained byunprotected cyclists diverted emergency room personnel and resources, thus

harming other patients >ones 1 ?ayer 233B%. 5he harm principle has beeninterpreted to include credible threat of significant economic harm to others as well

as physical harm. Eeturning again to smo6ing policy, various restrictions on thebehavior of smo6ers have been 0ustified by appeal to the financial burden on thehealth care system of caring for smo6ing=related illnesses. 94:
http://plato.stanford.edu/entries/publichealth-ethics/notes.html#6http://plato.stanford.edu/entries/publichealth-ethics/notes.html#6http://plato.stanford.edu/entries/publichealth-ethics/notes.html#6


14/29

As with all such principles, &uestions remain about its specification. owsignificant must the threat of harm be, with regard to both its li6elihood and

magnitude of effect Are physical harms to the health of others to be weightedmore than economic harms or other setbac6s to interests -hether interpreted

narrowly or broadly, there are limits to the public health cases that can plausibly beplaced in the harm principle box. Moreover, in the context of commitments to

social 0ustice and general welfare, and the other 0ustifications described above, tooexclusive a focus on the harm principle can undermine otherwise 0ustifiable

government mandates and regulation. It is undeniable that individuals have muchbroader and more multi=dimensional interests than narrowly self=directed physical

ones, and in that sense, it is not unreasonable to have a fairly expansiveunderstanding of harm in a public health context. owever, adherence to theO

admittedly somewhat artificialOheuristic of construing individuals8 interests asexclusively their self=regarding ones for purposes of determining what sacrifices

they may be as6ed to ma6e is an important way of ensuring chec6s on potentialabuses.

". Pate%nalis&

Jot surprisingly, paternalismOunderstood classically as interfering with the liberty

of action of a person, against her will, to protect or promote her welfareOis ascontroversial as the harm principle is uncontroversial *wor6in 233G Feinberg

"#$4%. Few public health interventions are 0ustified exclusively or even primarilyon unmediated, classic paternalistic grounds, although many more public health

programs may have paternalistic effects. ?y contrast, other classes of argumentsthat are sometimes described as paternalistic, including soft paternalism, wea6

paternalism, and libertarian paternalism, are evo6ed more fre&uently.

(oft and wea6 paternalism are usually interpreted as interchangeable, though they

have sometimes been ta6en to denote different concepts *wor6in 233%. Acommon interpretation defines this 6ind of paternalism as interferences with

choices that are compromised with regard to voluntariness or autonomy. 5hough aperson might voice or hold a preference different from the one that is sought for

her, her preference is not entitled to robust respect if it is formed under conditionsthat significantly compromise its autonomy or voluntariness, such as cognitive

disability or immaturity and, in very limited cases, ignorance or false beliefs.9B:Adaptive preferences are also considered compromised with regards to

autonomy7 sometimes, individuals modify their preferences in order to be able toadapt to difficult, un0ust, or undesirable circumstances. 9$:(uch preferences also do

not have the same standing as preferences formed under normal conditions and aretherefore viewed as sub0ect to interference.

It is important to note that in all these cases, 0ustified interference would be based

on conditions of autonomy@rationality that do or do not obtain in the formation orcontinued holding of particular preferences. 5his should not be confused with
http://plato.stanford.edu/entries/publichealth-ethics/notes.html#7http://plato.stanford.edu/entries/publichealth-ethics/notes.html#7http://plato.stanford.edu/entries/publichealth-ethics/notes.html#7http://plato.stanford.edu/entries/publichealth-ethics/notes.html#8http://plato.stanford.edu/entries/publichealth-ethics/notes.html#7http://plato.stanford.edu/entries/publichealth-ethics/notes.html#8


15/29

interference based on the content of particular preferences. !nly the former wouldbe 0ustifiable under wea6 or soft paternalism, whereas the latter would constitute

true or strong paternalism. As always, the demarcations are not as clear in practiceas one would wish from a theoretical point of viewOthe content of preferences is

often precisely what is appealed to in illustrating that a particular preference iscompromised in regards to autonomy or voluntarinessObut by and large, what

distinguishes soft paternalism from strong paternalism is the re&uirement that thedecision or preference be fundamentally compromised, and not simply that it be

mista6en or ignorant. 5his principled distinction remains important not leastbecause it reflects a difference in approach or attitude7 in the case of strong

paternalism, the interference is based on the content of a preference not reflectingwhat is ostensibly in the preference holder8s interest.9#:In the case of wea6 or soft

paternalism, persons might hold all manner of preferences not in their best interestthat are nonetheless not 0ustifiably interfered with because the relevant

compromising conditions do not obtain. In public health policy, soft paternalismhas been evo6ed to 0ustify interventions that limit the ability of adolescents to acton preferences for alcohol, drugs, sexual activity and driving.

Cibertarian paternalism defends interventions by planners such as public health

authorities% in the environmental architecture in which individuals decide and actin order to ma6e it easier for people to behave in ways that are in their best

interests including their health%, provided two conditions are satisfied 5haler 1(unstein 233;G 5haler 1 (unstein 233$%. First, individuals are steered by theseinterventions in ways that ma6e them better off, as 0udged by themselves. 5hus, in

libertarian paternalism there is no attempt to contravene the will of individuals, incontrast to what some hold to be a necessary feature of paternalism. (econd, the

interventions must not overly burden individuals who want to exercise theirfreedom in ways that run counter to welfare. In this sense, libertarian paternalism

claims to be liberty=preserving, hence libertarian.

A 6ey conceptual &uestion about paternalism is whether the interference withindividual liberty must be against the person8s will ?eauchamp 23"3%. If this

feature is a necessary condition of paternalism, then libertarian paternalism is

inappropriately titled. From the standpoint of public health ethics, however,whether libertarian paternalism is appropriately titled is less important than the

moral issues it raises and how it is 0ustified.

Cibertarian paternalism is grounded in the extensive empirical literature incognitive psychology and the decision sciences that support claims about our

cognitive limitations, bounded rationality and wea6ness of will. Although it raiseschallenging epistemic and political &uestions about how planners 6now what

individuals 0udge is in their interest in specific policy contexts, libertarianpaternalism may be well suited to public health contexts in which there is broad

public consensus in favor of health=promoting behaviors such as eating more fruitsand vegetables or getting more exercise, and a general recognition that it is difficult
http://plato.stanford.edu/entries/publichealth-ethics/notes.html#9http://plato.stanford.edu/entries/publichealth-ethics/notes.html#9http://plato.stanford.edu/entries/publichealth-ethics/notes.html#9http://plato.stanford.edu/entries/publichealth-ethics/notes.html#9


16/29

for people to act as prudentially as they would li6e. 5haler and (unstein suggest,for example, that salads rather than French fries could be made the default side

on restaurant menus, with diners free to re&uest fries if that remains theirpreference. At the same time, libertarian paternalism has been critici/ed for failing

to ta6e account of the manipulative effects on choice of some mar6et place forces.It has also been seen as too restrictive in its conditions and therefore too wea6% to

be applicable or ade&uate for many public health contexts Juffield )ouncil on?ioethics 233BG 'bel 233#%.

"./ Libe%t$0li&iting Cntinua an' A Cent%al Tas ! Public Health Ethics

+art of the appeal of libertarian paternalism in public health policy is that, at least

in certain contexts, it appears to sidestep or in some cases resolve the tensionbetween liberty and health. 5his tension ta6es center stage in some analyses of the

ethics of public health, as when public health policies are placed on autonomy=limiting continua and 0ustifications N and N4 dominate the analysis. A recent and

influential such continuum is the Juffield )ouncil8s intervention ladder Juffield)ouncil on ?ioethics 233B%, which is presented as a way of thin6ing about the

acceptability and 0ustification of public health policies. 5he ladder is anchored atone end by what is presented as the least intrusive option, doing nothing, and at the

other end by the what is presented as the most intrusive option, eliminating choicealtogether as in compulsory isolation%. 5he )ouncil ma6es plain that all rungs on

the ladder, including doing nothing, re&uire 0ustification and that the ladder is to beta6en only as a tool in the moral analysis of public health policies. owever, the

structure of the ladder and its attendant imagery reinforce the misleading view thatbalancing individual liberties with achieving health benefits is the primary moral

challenge of public health while at the same time appearing to emphasi/e ethicalconcerns about over=reaching the mission of public health over ethical concerns

about under=serving it.

)ontinua of this sort also oversimplify the complex impact of interventions on

choice and liberty and on relations between citi/ens and the state. Incentives arenot always less restrictive of choice than disincentives, and health promotion

campaigns, which are generally ran6ed at or near the least intrusive end of thecontinuum, are not always without significant moral concern. Ad campaigns that

are transparently sponsored by public health agencies to prevent transmission ofinfluen/a by promoting personal infection control practices or reduce obesity by

encouraging exercise and healthy eating do not raise the same moral issues as theembedding of anti=drug or abstinence messages in the story lines of entertainment

television programming by these same authorities F)) 2333G Forbes 2333 !therInternet Eesources%G Doodman 2334G Hrauthammer 2333G Hurt/ 1 -axman 2333%.

-hile the latter poses important &uestions about respect for liberty, governmentover=reaching and democratic legitimacy, the limited effectiveness of many ad

campaigns raises important &uestions about whether the state is under=serving itspublic health mission. Moreover, in the case of public health problems li6e obesity,


17/29

a reliance on health promotion campaigns and other strategies focused oninfluencing the behavior of individuals may fail to place appropriate burden on the

corporate interests and structural social ine&ualities that arguably account for muchof the problem. 5hus, depending on the circumstances, health promotion

campaigns may be un0ust as well as ineffective ?uchanan 233$G )rawford "##$GFaden "#$BG McCeroy, ?ibeau, (tec6ler, 1 Dlan/ "#$$%.

An important tas6 of public health ethics is not only to provide different moral0ustifications, but also to critically examine their relationship to one another in the

context of particular public health issues and activities so as to ensure a morecomplete moral picture of what is at sta6e, and to point out where no sufficient

0ustification exists. In this way, public health ethics can play a more immediatepractical role in public life7 by raising challenges to and providing moral scrutiny

of public health policies, it can contribute to creating an environment of

accountability where both abuses and deficiencies are less li6ely. 5hus, in additionto its intellectual significance, public health ethics can be an important element inthe scheme of chec6s and balances that help 6eep public health authorities from

overreaching or under=serving their mission.

*. #ustice an' Fai%ness in Public Health

-hether social 0ustice is viewed as a side constraint on the beneficence=based

foundation of public health, or as foundational in its own right, there is broadagreement that a commitment to improving the health of those who are

systematically disadvantaged is as constitutive of public health as is thecommitment to promote health generally +owers and Faden 2334, Institute of

Medicine8s )ommittee for the (tudy of the Future of +ublic ealth "#$$G 5homas2332G Juffield )ouncil on ?ioethics 233B%

In this regard, there is an intimate connection between public health and the fieldof health and human rights. Many in public health accept that there is a

fundamental right to health, as codified in the 'nited Jations 'niversal*eclaration of uman Eights or otherwise, although there is less agreement about

the 0ustification for such a right or what precisely the right entails DeneralAssembly "#


18/29

live in rich and poor countries constitute a profound in0ustice that is the duty of theglobal community to redress.

!ne tas6 of public health ethics is to identify which ine&ualities in health are themost egregious and thus which should be given high priority in public health

policy and practice. 5hat the life expectancy of some of world8s poorestpopulations is over forty years less than the life expectancy of those living in some

affluent countries is a clear in0ustice of particular moral urgency. Jot alline&ualities are so obviously egregious, however, and different accounts of 0ustice

and of the relevance of individual responsibility for health may yield differentconclusions. !n the view that +owers and Faden defend +owers 1 Faden 2334,

pp. #2P#%, social 0ustice demands that, insofar as possible, all children achieve asufficient level of health. 5hus, ine&ualities in the health of children are a particular

moral concern. 5he health of children is dependent on the decisions and actions of

others and on features of the social structure over which children have no control.5he value of health to children thus does not depend on what children can do forthemselves, as it sometimes does for adults. Moreover, the level of well=being

attainable in adulthood is in important respects conditioned by the level of healthachieved in childhood. )ompromised health in childhood has profound effects on

health in adulthood, as well as on the development of the cognitive s6ills necessaryfor reasoning and self determination.

-hen ine&ualities in health exist between socially dominant and sociallydisadvantaged groups, they are all the more important because they occur in

con0unction with other disparities in well=being and compound them +owers 1Faden 2334, pp. $BP#2%. Eeducing such ine&ualities are specific priorities in the

public health goals of national and international institutions *epartment of ealth233#G uropean 'nion 233# !ther Internet Eesources%G ealthy +eople 23"3,

233# !ther Internet Eesources%G Hettner 1 ?all 233


19/29

childhood vaccine programs from low to middle income countries can beprofoundly affected by 6eeping the moral function of vigilance with regard to

systematic disadvantage s&uarely in mind (hebaya, (utherland, Cevine, 1 Faden23"3, !ther Internet Eesources%.

!ne of the most difficult challenges for public health ethics emerges when thisimportant moral function conflicts with the in0unction to improve, if not maximi/e,

aggregate or collective health outcomes. Although the health of the world8s mostdesperately poor can in many cases be improved by extremely cost=efficient

interventions li6e basic childhood immuni/ations and vitamin supplementation,reducing other un0ust ine&ualities in health can consume significant resources. For

example, in the 'nited (tates, infant mortality rates are higher than in many otherwealthy nations, and they are higher still among poor and minority children. (ome

state public health authorities have made reducing racial disparities in infant

mortality a top priority, accepting the view that redressing this un0ust ine&uality isan urgent moral concern. !ther states have chosen the goal of improving infantsurvival statistics overall, on grounds that the same resources will produce greater

aggregate health outcomes while at the same time pointing to the special place thatall children should hold in public health policy E(A 233#, !ther Internet

Eesources%.

(till another challenge in social 0ustice for public health ethics emerges when the

health needs of systematically disadvantaged groups conflict with other dimensionsof well=being as well as with considerations of collective efficiency. 5argeting a

public health program to poor and minority communities can sometimes both servesocial 0ustice concerns and be efficient if, for example, the health problem the

intervention targets occurs disproportionately in these groups. At the same time,however, if the health problem is itself associated with stigma or shame, targeting

the poor and minorities may reinforce existing invidious stereotypes, therebyundermining another critical concern of social 0ustice, e&uality of social respect. In

such cases, public health authorities must decide whether a commitment to social0ustice re&uires foregoing an efficient, targeted program in favor of a relatively

inefficient, universal program that also may produce less improvement in health for

the disadvantaged group thus failing to narrow un0ust ine&ualities% in order toavoid exacerbating existing disrespectful social attitudes.

As noted in (ection 2, one of the structural features of public health is that the

individuals and groups affected by its policies and programs are not uniformlybenefited or burdened. -hen the burdens of a policy fall heavily on those who are

already disadvantaged, the 0ustificatory hurdle is particularly high. 5his concern isat the heart of many environmental 0ustice controversies such as the locating of

ha/ardous waste facilities and ha/ardous industries in low income communitiesand countries. Dlobal efforts to prevent and contain pandemic influen/as have also

placed significant burdens on the world8s poor. For example, a principal strategyemployed to prevent avian influen/a J" from becoming a human pandemic is


20/29

the destruction of infected birds and the banning of household poultry in urbansettings. Many families and women affected by this policy relied on their bac6yard

poultry as their only disposable source of income and have been economicallydevastated as a conse&uence. -ithout express focus on the interests of

disadvantaged people, the moral concerns this policy raises, particularly in theabsence of appropriate compensation and alternative livelihood opportunities,

might well go unnoticed ?ellagio -or6ing Droup 233B !ther InternetEesources%G Faden 1 Harron 233#G 'scher=+ines, *uggan, Daroon, Harron, 1

Faden 233B%.

+ublic health resources are always in short supply and priority setting in public

health policy and practice is always morally challenging. et another important setof tas6s for public health ethics is evaluating the role that formal economic and

decision theory methods such as cost benefit, cost effectiveness and cost utility

analysis do and should play in public health, including the continuing examinationof the moral assumptions embedded in these methods. Formal methods have beenused to varying degrees by public health authorities in numerous countries in such

diverse contexts as determining what ris6s should be regulated in environmentalhealth and in0ury prevention policy and in setting priorities for public health goals

and coverage decisions for health care systems. mbedded in these methods aremorally controversial assumptions. If the discount rate applied to future financial

costs and benefits is also applied to future health benefits, preventive interventionsare disvalued relative to interventions whose health benefits occur in the present(chwappach 233B%. Also problematic are willingness to pay measures as

proxies of the value of benefits or ris6 reduction. Arguably, these measures reifythe preferences of the privileged and fail to provide sufficient moral 0ustification

when ris6s materiali/e Dafni"##"%.

(ome formal methods, including most notably cost=utility analysis, rely on whatare referred to as summary health measures in which mortality and diverse

morbidities are combined in a single metric such as a &uality=ad0usted or disability=ad0usted life year. 5hese measures, and the formal methods that employ them,

sometimes rely on assessments of what may be only vague individual preferences

for trade=offs between different states of health or different 6inds of benefits.Moreover, they ma6e morally problematic assumptions including, for example,

whether to differentially value years saved in different stages of life and about howto disvalue specific disabilities. *epending on how these and other assumptions are

determined and specified, summary health measures have been critici/ed as beingageist or not ageist enough, as discriminating unfairly against people with

disabilities, as failing to capture the moral uni&ueness of life=saving, as treating ascommensurable &ualitatively different losses and benefits, and as failing to ta6e

ade&uate account of the claims of those who are most disadvantaged ?roc6 2332G*aniels 233$G Happel 1 (andoe "##2G Jord 233G +owers 1 Faden 2334G 'bel

"###G -illiams 233"%.


21/29

?ecause formal methods and summary measures do not reflect these and otherconsiderations of 0ustice, it is widely recogni/ed that formal methods should be

used solely as aids in public health policy and not as determinative in their ownright Cipscomb, *rummond, Frybac6, Dold, 1 Eevic6i 233#%.5hat said, there is a

powerful bias in favor of &uantification and the empirical in public health policy.5hus, there is the ris6 that the findings emerging from these formal analyses will

have determinative influence in policy circles. 5his ris6 is augmented by theincreasing interest in attempting to empirici/e moral considerations by measuring

and aggregating the value preferences of the public about moral tradeoffs such asprioriti/ing by age or life=saving potential ?a6er, ?ateman, 1 *onaldson 233$G

Men/el et al. "###G Jord "###%. 5hese aggregated preferences are thentransformed into weights intended to incorporate moral values directly into the

structure of the formal methodology, a move that is open to criticism onmethodological as well as substantive grounds. For example, moves of this sort

may obscure controversial moral considerations from public view and deliberation,undermining democratic values and political legitimacy. An important role for

public health ethics is to continue to loo6 critically at the role and specific methods

of economic and decision theory strategies for establishing priorities and regulatorystandards in public health, recogni/ing that considerations of cost=benefit and

efficiency are essential to public health programming and policy.

+. 2lbal #ustice

5hus far, no sharp distinctions have been drawn between the national and the

global context. >ust as in the economic, environmental and security arenas, it hasbecome increasingly difficult to discuss the demands of 0ustice withoutmetaphorically crossing national boundaries, so too from a public health point of

view. In this section, we survey six broad areas of global 0ustice concern thatdeserve further attention from a public health ethics point of view.

+.1 Resea%ch In but nt F% the Devel-ing 3%l'

Medical research is sometimes underta6en in the developing world in order to

further the understanding and treatment of diseases, not primarily for the benefit ofthose in the developing world, but rather for the benefit of citi/ens of the

developed world. In such cases, participants and their communities might wellclaim that they are entitled to share in the benefits of the research. owever,

compensation to participants and their communities is often non=existent or notnearly in line with the potential benefits their participation will bring to those

fortunate enough to have been born in a different geographical location ?enatar2332%. Jote that this is a different issue from the &uestion of whether researchers

wor6ing on indigenous diseases in the developing world have a duty to providemedical care or other ancillary services to their research sub0ects ?els6y 1

Eichardson 233


22/29

+." 4neven Resea%ch Fcus

Much medical research is focused on diseases that affect less than "3Q of the

world8s population, while millions die every year from diseases that potentiallycould be prevented or more easily treated if only enough research and other

medical resources were devoted to them. unt 1 'J conomic and (ocial)ouncil 233


23/29

whose access to such resources is limited by a mere luc6 of the draw. -here onehappens to be born in large part determines one8s ability to access medical and

other public health resources. In today8s global world, we all live in close enoughproximity to each other8s misfortunes that we cannot without disingenuousness

claim not to see it on our doorstep. 5his generates a particularly strong obligationto attend to the public health needs of those who are particularly vulnerable to

illness and disease and lac6 access to medical care and other critical resources.

+. 7utual (ene!it

Finally, there is a more pragmatic reason to attend to public health in thedeveloping world. ?eyond claims of 0ustice, morality, and common decency, we

live in a world where mobility and interaction within and across countries is veryhigh. *iseases such as (AE(, "J", and drug=resistant 5?, as well as less

headline=grabbing ailments such as cholera and malaria, are not neatly containedwithin one national boundary. )iti/ens of all countries would benefit from

improving public health in the developing world. )ontributing to the availabilityand improvement of medical, sanitary, and other health=related resources for those

who live in poverty and deprivation is ultimately good for us all, whether we are inthe habit of traveling around the world or not.

As was emphasi/ed in (ection ", public health is and ought to be about much morethan simply medical care and resources. 5his observation naturally extends to the

international arena. 5his section has focused specifically on 0ustice claims related

to public health and medical resources in part to distinguish concerns uni&ue to thiscontext from concerns that apply more broadly such as economic andenvironmental ones. ?ut improving public health in the developing world is

indelibly tied to economic, social, educational, and environmental improvements aswell, and health=related 0ustice claims are also not easily separable from 0ustice

claims that arise in those other contexts. 5he mere fact that there are people wholive in such poverty and deprivation that they and their children die of starvation

and the common cold should be a sufficient indicator that there is somethingseriously wrong with global institutional schemes, and that a 0ustice=based

obligation to remedy that situation, both from a public health point of view andmore broadly, exists.

(iblig%a-h$

'nited Jations Deneral Assembly "#"2, Condon7 )rown. 9Available online:.
http://www.haps.bham.ac.uk/publichealth/methodology/projects/RM03_JH12_CD.shtmlhttp://www.haps.bham.ac.uk/publichealth/methodology/projects/RM03_JH12_CD.shtml


24/29

?eauchamp, *. ., 1 (teinboc6, ?. ds%. "###&' (e) ethics for the

public*s health. Jew or67 !xford 'niversity +ress.

?eauchamp, 5. 23"3%. 5he concept of paternalism in biomedical ethics. In

?eauchamp, 5., +tanding on principles. pp. "3"P""#%. Jew or67 !xford'niversity +ress.

?els6y, C., 1 Eichardson, . (. 233


25/29

manuel, ., -endler, *., Hillen, >., 1 Drady, ). 233

Dafni, A. "##"%. -illingness=to=pay as a measure of benefits7 Eelevant

&uestions in the context of public decisionma6ing about health care

programs.Medical are, 2#"2%, "2


26/29

Happel, H., 1 (andoe, +. "##2%. TACs, age and fairness.ioethics, 4., 1 ?all, >. 233. C., Eichardson, >., 1

'bel, +. "###%. 5oward a broader view of values in cost=effectiveness analysis ofhealth. 5he astings enter :eport, 2#;%7 BP".

Mill, >. (. "$4#%. In Dray >. d.%, 9n liberty . other essays(econd ed.%

Jew or67 !xford 'niversity +ress, "##$.

Miller, ., -aight, +., Day, J., Eamsay, M., urdien, >., Morgan=)apner, +.,

et al. "##B%. 5he epidemiology of rubella in england and wales before and after

the "##< measles and rubella vaccination campaign7 Fourth 0oint report from the+C( and the national congenital rubella surveillance programme. ommunicable

isease :eport:evie), B2%, E24P;2.

Jord, . "###%. 5owards cost=value analysis in health careealth are

Analysis, B2%, "4BP"B.


27/29

PPP 233%. )oncerns for the worse off7 Fair innings versus severity. +ocial

+cience . Medicine, 432%, 2BP24;.

Juffield )ouncil on ?ioethics. 233B%."ublic health! /thical issues.

)ambridge7 )ambridge +ublishers.

!mer, (. ?., (almon, *. A., !renstein, -. A., deart, M. +., 1 alsey, J.

233#%. accine refusal, mandatory immuni/ation, and the ris6s of vaccine=

preventable diseases. 5he (e) /ngland -ournal of Medicine, ;43"#%, "#$"P"#$$.

!renstein, -. A., 1 inman, A. E. "###%. 5he immuni/ation system in the

united statesOthe role of school immuni/ation laws. =accine, "B(upplement ;%,("#=(2-ashington7

?roo6ings Institution +ress.

(chwappach, *. C. ?. 233B%. 5he economic evaluation of preventionO

Cet8s tal6 about values and the case of discounting.8nternational -ournal of "ublicealth, 24%, ;;P;;4.

5haler, E. ., 1 (unstein, ). E. 233;%. Cibertarian paternalism.American

/conomic :evie), 3


28/29

childhood immuni/ation rates.American -ournal of "reventive Medicine, ;2;%,"#


29/29

beneficence, principle ofX ethics, biomedical7 0ustice, ine&uality, and healthX ethics,biomedical7 0ustice and access to health careX ethics, biomedical7 privacy and

medicineX0ustice7 internationalXpaternalismX public health7 international

Acn8le'g&ents

(ection < draws heavily on +owers 1 Faden 2334, )hapters < and 4.

-e gratefully ac6nowledge >+ Ceider for his invaluable assistance in preparing thismanuscript.

Copyright 2010by

Ruth Faden Sirine Shebaya
http://plato.stanford.edu/entries/principle-beneficence/http://plato.stanford.edu/entries/justice-inequality-health/http://plato.stanford.edu/entries/justice-healthcareaccess/http://plato.stanford.edu/entries/justice-healthcareaccess/http://plato.stanford.edu/entries/privacy-medicine/http://plato.stanford.edu/entries/privacy-medicine/http://plato.stanford.edu/entries/international-justice/http://plato.stanford.edu/entries/paternalism/http://plato.stanford.edu/info.html#cmailto:[email protected]:[email protected]://plato.stanford.edu/entries/principle-beneficence/http://plato.stanford.edu/entries/justice-inequality-health/http://plato.stanford.edu/entries/justice-healthcareaccess/http://plato.stanford.edu/entries/justice-healthcareaccess/http://plato.stanford.edu/entries/privacy-medicine/http://plato.stanford.edu/entries/privacy-medicine/http://plato.stanford.edu/entries/international-justice/http://plato.stanford.edu/entries/paternalism/http://plato.stanford.edu/info.html#cmailto:[email protected]:[email protected]

Documents

Stanford Encyclopaedia Ph Ethics