It is well established that moral mandates sit at the core of good public health policy and practice. Though they may sometimes prove to be competing commitments, the key aims of public health –promoting overall levels of health and addressing inequitable health inequalities – are goals derived directly from ethical commitments to ideas of justice. As the field of public health ethics has emerged, it has become clear that moral values, rationales, imperatives and constraints may be found in quite distinct sources: the ethics of the profession itself; the ethics of advocacy for the public’s health; and from philosophical theory. It is clear, furthermore, that given its focus on populations and on governmental and institutional power, public health ethics is about politics. As suggested in the subtitle to Lawrence Gostin and Lindsay Wiley’s celebrated textbook on public health law, attention must be paid to political and legal ‘power, duty and restraint’. Here in the UK, as elsewhere, we need to meet the challenge of establishing the contours of ethical public health practice and policy, and explain how far public health ethics should bear on overall social and political agendas.
If public health is to provide a voice – to provide leadership – political disagreement is inevitable. This is only heightened in a context of increasing fiscal pressures on public health authorities, and concerns about the fragmentation of the public health workforce and its overall independence. Across the political spectrum, furthermore, we find an array of views of where public responsibilities begin and purely personal responsibilities end. Without an identifiable ethical core, public health becomes an eclectic range of technical specialities, serving diverse technical, organisational, political, and corporate interests and outcomes. In a scathing comment piece calling for stronger public health leadership, and criticising the relationship of public health’s leadership with government, Richard Horton wrote in 2011:
There was a time when public health in England was driven by passionately articulated values and compelling research, a time when its leaders were concerned about social reform and political change. […] Public health is the science of social justice, overcoming the forces that undermine the future security of families, communities and peoples. Public health leadership in England is failing. It is time for those leaders to discover courage and purpose.
Some representatives of the targets of these powerful words offered a response. And we do, of course, find crucial bases of public health leadership such as the Academy of Medical Science’s ‘Improving the Health of the Public by 2040’. An important lesson to take from the above reflections, though, and the exchanges on public health leadership, is that debates and practical argument are required on how we understand the substance and scope of ethical public health agendas, recognising both their inherently political nature and the wider social, political, and economic contexts in which they exist. This means examining questions such as:
- The substance of ethical public health goals: to what ends should public health activity be directed?
- The means by which public health agendas should be achieved: what methods of intervention may, or may not, be justified, and what further, non-health-related values might sometimes take precedence?
- The reach of public health ethics: is an ethical mandate from a public health perspective a compelling social and political mandate overall?
- The relationship of public health practitioners, leaders and advocates with communities and political agencies: what interests are being represented, and what is the right level of political independence?
- The need for ethics education and the development of ethics as a competency: how do we understand such a competency, and how is it best promoted within the public health workforce?
We do not suggest that any of these questions will receive a single, unanimously agreed answer. But consensus and leadership are needed where they can be found, and such questions must be visited and revisited as the political and social landscapes change, and as public health emergencies and challenges arise. This editorial is a call to advance such discourse on public health ethics and law, with a view to providing both a point of reflection and a call to action.
The Journal of Public Health is accordingly planning a special section on the ethical foundations of public health ethics and law, and the implications for policy and practice. Scholars, practitioners, leaders and policy makers are invited to contribute articles, including research articles, perspectives, and Chekhov’s corner.
If you wish to submit a piece, you are encouraged to consult Farhang Tahzib, firstname.lastname@example.org, on your proposed submission. However, submissions will be made through the journal’s usual Manuscript Central portal, by 15 January 2018.
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