Public health ethics, like the field of public health it addresses, traditionally has focused more on practice and particular cases than on theory, with the result that some concepts, methods, and boundaries remain largely undefined. This paper attempts to provide a rough conceptual map of the terrain of public health ethics. We begin by briefly defining public health and identifying general features of the field that are particularly relevant for a discussion of public health ethics.Public health is primarily concerned with (...) the health of the entire population, rather than the health of individuals. Its features include an emphasis on the promotion of health and the prevention of disease and disability; the collection and use of epidemiological data, population surveillance, and other forms of empirical quantitative assessment; a recognition of the multidimensional nature of the determinants of health; and a focus on the complex interactions of many factors—biological, behavioral, social, and environmental—in developing effective interventions. (shrink)

Few novel or emerging infectious diseases have posed such vital ethical challenges so quickly and dramatically as the novel coronavirus SARS‐CoV‐2. The World Health Organization declared a public health emergency of international concern and recently classified Covid‐19 as a worldwide pandemic. As of this writing, the epidemic has not yet peaked in the United States, but community transmission is widespread. President Trump declared a national emergency as fifty governors declared state emergencies. In the coming weeks, hospitals will become overrun, stretched (...) to their capacities. When the health system becomes stretched beyond capacity, how can we ethically allocate scarce health goods and services? How can we ensure that marginalized populations can access the care they need? What ethical duties do we owe to vulnerable people separated from their families and communities? And how do we ethically and legally balance public health with civil liberties? (shrink)

Hastings Center Report, Volume 52, Issue 1, Page 15-20, January/February 2022.

The late Jonathan Mann famously theorized that public health, ethics, and human rights are complementary fields motivated by the paramount value of human well-being. He felt that people could not be healthy if governments did not respect their rights and dignity as well as engage in health policies guided by sound ethical values. Nor could people have their rights and dignity if they were not healthy. Mann and his colleagues argued that public health and human rights are integrally connected: Human (...) rights violations adversely affect the community's health, coercive public health policies violate human rights, and advancement of human rights and public health reinforce one another. Despite the deep traditions in public health, ethics, and human rights, they have rarely cross-fertilized—although there exists an important emerging literature. For the most part, each of these fields has adopted its own terminology and forms of reasoning. Consequently, Mann advocated the creation of a code of public health ethics and the adoption of a vocabulary or taxonomy of “dignity violation”. (shrink)

The late Jonathan Mann famously theorized that public health, ethics, and human rights are complementary fields motivated by the paramount value of human well-being. He felt that people could not be healthy if governments did not respect their rights and dignity as well as engage in health policies guided by sound ethical values. Nor could people have their rights and dignity if they were not healthy. Mann and his colleagues argued that public health and human rights are integrally connected: Human (...) rights violations adversely affect the community's health, coercive public health policies violate human rights, and advancement of human rights and public health reinforce one another. Despite the deep traditions in public health, ethics, and human rights, they have rarely cross-fertilized—although there exists an important emerging literature. For the most part, each of these fields has adopted its own terminology and forms of reasoning. Consequently, Mann advocated the creation of a code of public health ethics and the adoption of a vocabulary or taxonomy of “dignity violation”. (shrink)

McDonough Hall, Room 508, 600 New Jersey Ave, NW, Washington, DC 20001, USA; Email: gostin{at}law.georgetown.edu ' + u + '@' + d + ' '//--> Abstract As a consequence of rapid globalization, the need for a coherent system of global health law and governance has never been greater. This article explores the health hazards posed by contemporary globalization on human health and the consequent urgent need for global health law to facilitate effective multilateral cooperation in advancing the health of populations (...) equitably. It sets forth the first definition of the emerging field of "global health law." After explicating the central features identified in the definition, the article examines the "grand challenges" to reaching the full potential of global health law to advance human health in just and effective ways. CiteULike Connotea Del.icio.us What's this? (shrink)

Health inequalities are embedded in a complex array of social, political, and economic inequalities. Responding to health inequalities will require systematic action targeting all the underlying (“upstream”) social determinants that powerfully affect health and well‐being. Systemic inequalities are a major reason for the rise of modern populism that has deeply divided polities and infected politics, perhaps nowhere more so than in the United States. Concerted action to mitigate shocking levels of inequality could be a powerful antidote to nationalist populism. A (...) basic yet critical start to addressing health inequalities is to recognize them, which demands improving data collection and analysis. Certainly, global indicators show vast progress in reducing poverty and extending life. Yet aggregate health data mask a deeper reality: health gains have disproportionately benefited the well‐off, leaving the poor and middle‐class behind. (shrink)

The Lancet–O’Neill Institute/Georgetown University Commission on Global Health and Law published its report on the Legal Determinants of Health in 2019. The term ‘legal determinants of health’ draws attention to the power of law to influence upstream social and economic influences on population health. In this article, we introduce the Commission, including its background and rationale, set out its methodology, summarize its key findings and recommendations and reflect on its impact since publication. We also look to the future, making suggestions (...) as to how the global health community can make the best use of the Commission’s momentum in relation to using law and legal tools to advance population health. (shrink)

The adoption of the new International Health Regulations in May 2005 represents an historic development for international law and public health. This article describes the IHR revision process and analyzes why the new IHR constitute an advance in global health governance.

The World Health Assembly adopted the new International Health Regulations on May 23, 2005. The new IHR represent the culmination of a decade-long revision process and an historic development for international law and public health. The new IHR appear at a moment when public health, security, and democracy have become intertwined, addressed at the highest levels of government. The United Nations Secretary-General Kofi Annan, for example, identified IHR revision as a priority for moving humanity toward “larger freedom.” This article analyzes (...) the new IHR and their implications for global health and security in the 21st century.The WHA instructed the WHO Director-General to revise the IHR in 1995 because the Regulations did not provide an effective framework for addressing the international spread of disease. Doubts about the IHR's effectiveness had, however, been present long before 1995. The critiques identified the narrow scope of the regulations, the lack of compliance by states, and the absence of a strategy for responding to rapid changes in public health's global economic and technological environments. (shrink)

In the past ten years, there has been growing interest in and concern about protecting the privacy of personal medical information. Insofar as medical records increasingly are stored electronically, and electronic information can be shared easily and widely, there have been legislative efforts as well as scholarly analyses calling for greater privacy protections to ensure that patients can feel safe disclosing personal information to their health-care providers. At the same time, the volume of biomedical research conducted in this country continues (...) to grow. The budget of the National Institutes of Health, for example, was $20,298 million in 2001, having more than doubled from a budget of $9,218 million 10 years before. This growing body of research includes increased efforts to use stored medical records as a source of data for health services, epidemiologic, and clinical studies. (shrink)

Michael Bloomberg assumed office as the 108th mayor of New York City on January 1, 2002. As he leaves the mayoralty—having won re—election twice‐his public health legacy is bitterly contested. The public health community views him as an urban innovator—a rare political and business leader willing to fight for a built environment conducive to healthier, safer lifestyles. To his detractors, Bloomberg epitomizes a meddling nanny—an elitist dictating to largely poor and working—class people about how they ought to lead their lives. (...) His policies have sparked intense public, corporate, and political ire—critical of sweeping mayoral power to socially engineer the city and its inhabitants. Here, I seek to show how Bloomberg has fundamentally changed public health policy and discourse. He has used the engine of government to make New York City a laboratory for innovation‐raising the visibility of public health, testing policy effectiveness, and probing the boundaries of state power. Even though the courts have blocked some of his boldest initiatives, he has offered a paradigm for the “new public health”—reaching beyond infectious diseases to upstream risk factors in everyday life and the human habitat. I also critically probe various arguments designed to derail his policies, along with the overarching charge of unjustified paternalism. (shrink)

Human genomic information is invested with enormous power in a scientifically motivated society. Genomic information has the capacity to produce a great deal of good for society. It can help identify and understand the etiology and pathophysiology of disease. In so doing, medicine and science can expand the ability to prevent and ameliorate human malady through genetic testing, treatment, and reproductive counseling.Genomic information can just as powerfully serve less beneficent ends. Information can be used to discover deeply personal attributes of (...) an individual's life. That information can be used to invade a person's private sphere, to alter a person's sense of self- and family identity, and to affect adversely opportunities in education, employment, and insurance. Genomic information can also affect families and ethnic groups that share genetic similarities. (shrink)

The incident in May-June 2007 involving a U.S. citizen traveling internationally while infected with drug-resistant tuberculosis involved the U.S. federal government's application of its quarantine and isolation powers. The incident and the isolation order raised numerous important issues for public health governance, law, and ethics. This article explores many of these issues by examining how the exercise of quarantine powers provides a powerful lens through which to understand how societies respond to and attempt to govern threats posed by dangerous, contagious (...) pathogens. The article considers historical aspects of governmental power to quarantine and isolate individuals and groups; analyzes the current state of quarantine and isolation law in the United States in light of the recent incident with drug-resistant tuberculosis; and explores global aspects of public health governance and law highlighted by this incident. (shrink)

Human genomic information is invested with enormous power in a scientifically motivated society. Genomic information has the capacity to produce a great deal of good for society. It can help identify and understand the etiology and pathophysiology of disease. In so doing, medicine and science can expand the ability to prevent and ameliorate human malady through genetic testing, treatment, and reproductive counseling.Genomic information can just as powerfully serve less beneficent ends. Information can be used to discover deeply personal attributes of (...) an individual's life. That information can be used to invade a person's private sphere, to alter a person's sense of self- and family identity, and to affect adversely opportunities in education, employment, and insurance. Genomic information can also affect families and ethnic groups that share genetic similarities. (shrink)

In the past ten years, there has been growing interest in and concern about protecting the privacy of personal medical information. Insofar as medical records increasingly are stored electronically, and electronic information can be shared easily and widely, there have been legislative efforts as well as scholarly analyses calling for greater privacy protections to ensure that patients can feel safe disclosing personal information to their health-care providers. At the same time, the volume of biomedical research conducted in this country continues (...) to grow. The budget of the National Institutes of Health, for example, was $20,298 million in 2001, having more than doubled from a budget of $9,218 million 10 years before. This growing body of research includes increased efforts to use stored medical records as a source of data for health services, epidemiologic, and clinical studies. (shrink)

Dramatic events involving dangerous microbes often focus attention on isolation and quarantine as policy instruments. The incident in May-June 2007 involving Andrew Speaker and drug-resistant tuberculosis joins other communicable disease crises that have forced contemplation or actual application of quarantine powers. Implementation of quarantine powers, which encompasses authority for both isolation and quarantine actions, is important not only for the handling of a specific event but also because the use of such authority provides a window on broader issues of public (...) health and the legal rules, ethical principles, and governance systems that support it. Debates about quarantine powers reflect political and social attitudes about public health that often tell us more about this policy endeavor than acts of isolation and quarantine themselves. (shrink)

Reviews the legal position on the distinction drawn between killing and letting die in medically assisted dying.

In 2007, many legislatures considered, and two enacted, bills mandating HPV vaccination for young girls as a condition of school attendance. Such mandates raise signifcant legal, ethical, and social concerns. This paper argues that mandating HPV vaccination for minor females is premature since long-term safety and efectiveness of the vaccine has not been established, HPV does not pose imminent and signifcant risk of harm to others, a sex specifc mandate raises constitutional concerns, and a mandate will burden fnancially existing government (...) health programs and private physicians. Absent careful consideration and public conversation, HPV mandates may undermine coverage rates for other vaccines. (shrink)

The human papillomavirus is the most common sexually transmitted infection worldwide. In the United States, more than six million people are infected each year. Although most HPV infections are benign, two strains of HPV cause 70 percent of cervical cancer cases. Two other strains of HPV are associated with 90 percent of genital warts cases.In June 2006, the Food and Drug Administration approved the first vaccine against HPV. Sold as Gardasil, the quadrivalent vaccine is intended to prevent four strains of (...) HPV associated with cervical cancer, precancerous genital lesions, and genital warts. Following FDA approval, the national Advisory Committee on Immunization Practices recommended routine vaccination for girls ages 11-12 with three doses of quadrivalent HPV vaccine. Thereafter, state legislatures around the country engaged in an intense effort to pass laws mandating vaccination of young girls against HPV. This activity was spurred in part by an intense lobbying campaign by Merck, the manufacturer of the vaccine. (shrink)

Traditional medical ethics and law draw a sharp distinction between allowing a patient to die and helping her die. Withholding or withdrawing life sustaining treatment, such as by abating technological nutrition, hydration or respiration, will cause death as surely as a lethal injection. The former, however, is a constitutional right for a competent or once-competent patient, while the latter poses a risk of serious criminal or civil liability for the physician, even if the patient requests it.

From my perspective, as a White House official watching the budgetary process, and subsequently as head first of a health care financing agency and then of a public health agency, I was continually amazed to watch as billions of dollars were allocated to financing medical care with little discussion, whereas endless arguments ensued over a few millions for community prevention programs. The sums that were the basis for prolonged, and often futile, budget fights in public health were treated as rounding (...) errors in the Medicare budget.William Roper. (shrink)

From my perspective, as a White House official watching the budgetary process, and subsequently as head first of a health care financing agency and then of a public health agency, I was continually amazed to watch as billions of dollars were allocated to financing medical care with little discussion, whereas endless arguments ensued over a few millions for community prevention programs. The sums that were the basis for prolonged, and often futile, budget fights in public health were treated as rounding (...) errors in the Medicare budget.William Roper. (shrink)

The threat posed by avian influenza appears to be rising, yet global and national health programs are preparing only fitfully. A lethal form of avian flu has rooted itself deeply into the poultry flocks of poor Asian countries that will have a hard time eradicating it. Every so often a sick bird infects a human, who usually dies from the encounter, and on rare occasions the virus seems to have spread from one person to another before the chain of infection (...) dies out. All it would take to set off a raging global pandemic would be for the virus to mutate into a form that is readily transmissible among humans. Severe Acute Respiratory Syndrome garnered a great deal of public attention because it was novel and its potential for spread was unknown. However, the SARS corona virus is significantly less virulent than pandemic influenza viral infections. (shrink)

The threat posed by avian influenza appears to be rising, yet global and national health programs are preparing only fitfully. A lethal form of avian flu has rooted itself deeply into the poultry flocks of poor Asian countries that will have a hard time eradicating it. Every so often a sick bird infects a human, who usually dies from the encounter, and on rare occasions the virus seems to have spread from one person to another before the chain of infection (...) dies out. All it would take to set off a raging global pandemic would be for the virus to mutate into a form that is readily transmissible among humans.Severe Acute Respiratory Syndrome garnered a great deal of public attention because it was novel and its potential for spread was unknown. However, the SARS corona virus is significantly less virulent than pandemic influenza viral infections. (shrink)

In 2000, the Center for Disease Control and Prevention’s National Center for Environmental Health issued a report that explored some of the ways in which “sprawl” impacts public health. The report has generated great interest, and state health officials are beginning to discuss the relationship between land use and public health. The CDC report has also produced a backlash. For example, the Southern California Building Industry Association labeled the report “a ludicrous sham” and argued that the CDC should stick to (...) “fighting physical diseases, not defending political ones.”In retrospect, it is probably unfortunate that this report was funded by an organization called “Sprawl Watch.” “Spraw” is a word that has no clear meaning but is applied to a huge range of issues involving suburban development. (shrink)

In 2000, the Center for Disease Control and Prevention’s National Center for Environmental Health issued a report that explored some of the ways in which “sprawl” impacts public health. The report has generated great interest, and state health officials are beginning to discuss the relationship between land use and public health. The CDC report has also produced a backlash. For example, the Southern California Building Industry Association labeled the report “a ludicrous sham” and argued that the CDC should stick to (...) “fighting physical diseases, not defending political ones.”In retrospect, it is probably unfortunate that this report was funded by an organization called “Sprawl Watch.” “Spraw” is a word that has no clear meaning but is applied to a huge range of issues involving suburban development. (shrink)

Even as public health ethics was developing as a field, major incidents such as 9/11 and the SARS epidemic propelled discourse around public health emergency preparedness and response. Policy and practice shifted to a multidisciplinary approach, recognizing the broad range of potential threats to public health, including biological, physical, radiological, and chemical threats. This propelled the development of surveillance systems to detect incidents, laboratory capacities to rapidly test for potential threats, and therapeutic and social countermeasures to prepare for and respond (...) to a range of hazards. In bringing public health ethics and emergency preparedness together, Emergency Ethics: Public Health Preparedness and Response adds depth and complexity to both fields. As global threats continue to emerge, the book, edited by Bruce Jennings, John D. Arras, Drue H. Barrett, and Barbara A. Ellis, will offer a vital compass. (shrink)

As we write, U.S. cities and states with extensive community transmission of Covid‐19 are in harm's way—not only because of the disease itself but also because of prior and current failures to act. During the 2009 influenza pandemic, public health agencies and hospitals developed but never adequately implemented preparedness plans. Focused on efficiency in a competitive market, health systems had few incentives to maintain stockpiles of essential medical equipment. Just‐in‐time economic models resulted in storage of only those supplies needed then. (...) At the same time, global purchasing in search of lower prices reduced the number of U.S. suppliers, with hospitals dependent on foreign companies. There is still a possibility that the pandemic will be manageably bad rather than unmanageably catastrophic in this country. Immediate, powerful, and sustained federal action could make the difference. (shrink)

Law is an essential tool for public health practice, and the use of a systematic legal framework can assist with preventing chronic diseases and addressing the growing epidemic of obesity.The action options available to government at the federal, state, local, and tribal levels and its partners can help make the population healthier by preventing obesity and decreasing the growing burden of associated chronic diseases such as cardiovascular disease and Type 2 diabetes. The Centers for Disease Control and Prevention uses the (...) four-part systematic legal framework commonly referred to as “public health legal preparedness” to demonstrate the essential role law can play for any public health issue. This paper uses the “laws and legal authorities” component of the framework and should be considered in combination with the competencies, coordination, and information-best practices components of the framework. (shrink)

Law is an essential tool for public health practice, and the use of a systematic legal framework can assist with preventing chronic diseases and addressing the growing epidemic of obesity.The action options available to government at the federal, state, local, and tribal levels and its partners can help make the population healthier by preventing obesity and decreasing the growing burden of associated chronic diseases such as cardiovascular disease and Type 2 diabetes. The Centers for Disease Control and Prevention uses the (...) four-part systematic legal framework commonly referred to as “public health legal preparedness” to demonstrate the essential role law can play for any public health issue. This paper uses the “laws and legal authorities” component of the framework and should be considered in combination with the competencies, coordination, and information-best practices components of the framework. (shrink)

This article introduces a special issue on the legal determinants of health, following the publication of the Lancet–O’Neill Institute of Georgetown University Commission’s report on the subject. We contextualize legal determinants as a significant and vital aspect of the social determinants of health, explain the work of the Lancet–O’Neill Commission and outline where consequent research will usefully be directed. We also introduce the papers that follow in the special issue, which together set out in greater detail the work of the (...) Commission and critically engage with different aspects of the report and the application of its findings and recommendations. (shrink)

This is a short postscript to the Public Health Ethics special issue on the legal determinants of health. We reflect briefly on emerging responses to COVID-19, and raise important questions of ethics and law that must be addressed; including through the lens of legal determinants, and with critical attention to what it means to protect health with justice.

Over two hundred years ago, Thomas Jefferson suggested the need for a broader legal curriculum. As the twenty-first century begins, the practice of law will increasingly demand interdisciplinary knowledge and collaboration — between those trained in law and a broad range of scientific and technical fields, including engineering, biology, genetics, ethics, and the social sciences. The practice of public health law provides a model for both the substantive integration of law with science, and for the way its practitioners work. In (...) addition, public health law also provides a model for interdisciphuy and integrative teaching. (shrink)

It was October 2014, and Ebola was raging out of control in Guinea, Liberia, and Sierra Leone. Margaret Chan, the World Health Organization's director‐general, defended the organization against charges that its response was late and ineffective: “We are a technical agency, with governments having first priority to take care of their people.” In January 2015, the WHO executive board undertook a systematic reform of the agency's performance, and Chan again offered a defense: I followed protocol, leaving it to the Africa (...) office (AFRO) to respond. Yet the three nations could not possibly have stemmed the outbreak alone, and AFRO was known to be dysfunctional.Ebola represents an inflection point requiring fundamental reform for the WHO. A failure of leadership will impact its status and legitimacy for a generation. Here, I offer five reforms that would transform it and ensure that it fulfills its constitutional mission as “the directing and coordinating authority on international health work.”. (shrink)

Over two hundred years ago, Thomas Jefferson suggested the need for a broader legal curriculum. As the twenty-first century begins, the practice of law will increasingly demand interdisciplinary knowledge and collaboration — between those trained in law and a broad range of scientific and technical fields, including engineering, biology, genetics, ethics, and the social sciences. The practice of public health law provides a model for both the substantive integration of law with science, and for the way its practitioners work. In (...) addition, public health law also provides a model for interdisciphuy and integrative teaching. (shrink)

This paper is one of four interrelated action papers resulting from the 2008 National Summit on Legal Preparedness for Obesity Prevention and Control. Summit participants engaged in discussions on the current state of the law with respect to obesity, nutrition and food policy, physical activity, and physical education. Participants also identified gaps in the law at all jurisdictional levels and relevant to numerous sectors and disciplines that have a stake in obesity prevention and control.The companion paper, “Assessment of Laws and (...) Legal Authorities for Obesity Prevention and Control,”identified numerous laws and policies enacted to target the three domains of healthy lifestyles, healthy places, and healthy societies. That paper identified several gaps in the law that require attention and action. This paper addresses those gaps and presents applicable laws and legal authorities that public health professionals and lawyers can consider to implement to close the gaps. (shrink)

Administraation of antiretroviral therapy to women during pregnancy, labor and delivery, and to infants postnatally can dramatidy reduce mother-to- child HIV transmission. However, pregnant women need to know that they are HIV-infected to take advantage of antiretroviral therapy, and many women do not know their HIV status. One-half of HIV-infected infants in the United States were bornto women who had not been tested for HIV or for whom the time of testing was not known. Although fewer than 400infants are infected (...) perinatally in the United States each year, that number could be reduced even further through policies aimed at HIV testing during pregnancy.The reasons toadopt such a policy are strong: the pathophysiology of perinatal transmission is clear, prophylaxis is effective and safe, and the intended beneficiaries of the intervention - babies - cannot protect themselves. (shrink)

Administraation of antiretroviral therapy to women during pregnancy, labor and delivery, and to infants postnatally can dramatidy reduce mother-to- child HIV transmission. However, pregnant women need to know that they are HIV-infected to take advantage of antiretroviral therapy, and many women do not know their HIV status. One-half of HIV-infected infants in the United States were bornto women who had not been tested for HIV or for whom the time of testing was not known. Although fewer than 400infants are infected (...) perinatally in the United States each year, that number could be reduced even further through policies aimed at HIV testing during pregnancy.The reasons toadopt such a policy are strong: the pathophysiology of perinatal transmission is clear, prophylaxis is effective and safe, and the intended beneficiaries of the intervention - babies - cannot protect themselves. (shrink)

In this article, Gostin and Archer explore the varied lenses through which governments are obligated to address humanitarian needs. States’responsibilities to help others derive from domestic law, political commitments, ethical values, national interests, and international law. What is needed, however, is clarity and detailed standards so that States can operationalize this responsibility, making it real for developing countries. Transnational cooperation needs to be more effective and consistent to provide assistance for the world's poorest and least healthy people.