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)

In the decade since the first edition of Global Health Law was published, the world has moved incrementally towards global health with justice, at least by one basic metric: life expectancy has edged up globally, with more rapid gains in low- than high-income countries. But to look around the world, global health with justice still seems a distant dream. Health gaps between people in rich and poor countries remain shocking and unconscionable—as do health inequities within countries. The pandemic also gave (...) salience to profound health injustices—from injustices in access to lifesaving vaccines to gaping disparities in morbidity and mortality based on income, race, and national origin. So did the Trump administration’s decision to pause, and then slash, foreign assistance, bringing an end to lifesaving programs around the world. Guided by the overarching theme of justice, these reflections canvass the history of global health law as a field and discuss developments and challenges in the field across four core themes: multilateralism; equitable distribution of the benefits of scientific advancement; global health law for the poly-crises; and human rights and equity. (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)

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)

This is a pivotal moment in the global governance response to pandemic threats, with crucial global health law reforms being undertaken simultaneously in the coming years: the revision of the International Health Regulations, the implementation of the GHSA Legal Preparedness Action Package, and the negotiation of a new Pandemic Treaty. Rather than looking at these reforms in isolation, it will be necessary to examine how they fit together, considering: how these reforms can complement each other to support pandemic prevention, preparedness, (...) and response; what financing mechanisms are necessary to ensure sustainable health governance; and why vital norms of equity, social justice, and human rights must underpin this new global health system. (shrink)

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

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)

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)

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)

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)

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)

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)

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.

This symposium issue of the Journal of Law, Medicine & Ethics is about public health law, not health-care law. There is a difference. Most scholarly writing has examined the rich and textured field of health-care law or law and medicine. This field revolves around several broad themes related to the health-care system: delivery, financing, and research and innovation.In studying health-care delivery, scholars have examined everything from the physician/patient relationship to systems of care. In studying financing, scholars have examined theories of (...) competition and justice to ensure cost-efficient access to care. And in studying research and innovation, scholars have studied everything from human subject protection to intellectual property. (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)

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)

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)

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)

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)

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)

Should government have the power to place limits on a scientific pursuit that holds the potential for both good and harm—on what is called “dual‐use research”? That is the highly charged question surrounding research to genetically modify influenza A (H5N1) to render it more easily transmissible from human to human. There is seldom a “right” answer to dual‐use research, but a fair, inclusive, and transparent process—building on the NSABB model—should improve decision‐making. A local institutional panel should evaluate dual‐use research based (...) on the following structured ethical 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)

Human rights law is a powerful, but often neglected, tool in advancing the rights and freedoms of persons with mental disabilities. International law may seem marginal or unimportant in developed countries with democratic and constitutional systems of their own. Yet, even democracies often resist reform of mental health law and policy, and domestic courts do not always compel changes necessary for the rights and welfare of persons with mental disabilities. Additionally, human rights are obviously important for countries without democratic and (...) constitutional systems because they may provide the only genuine safeguard against abuse of persons with mental disabilities ostensibly based on political, social, or cultural justifications. (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.

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)

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)

This article deals with a foreign policy question of extraordinary importance: what responsibilities do States have to provide economic and technical assistance to other States that have high levels of need affecting the health and life of their citizens? The question is important for a variety of reasons. There exist massive inequalities in health globally, with the result that poorer countries shoulder a disproportionate burden of disease and premature death. Average life expectancy in Africa is nearly 30 years shorter than (...) in the Americas or Europe. In one year alone, an estimated 14 million of the poorest people in the world died, while only an estimated four million would have died if this population had the same death rate as the global rich. (shrink)

It is staggering to observe the new normal in America: 37.9 percent of adults are obese, and 70.7 percent are either obese or overweight. One out of every five minors is obese. The real tragedy, of course, is the disability, suffering, and early death that devastates families and communities. But all of society pays, with the annual medical cost estimated at $147 billion. The causal pathways are complex, but if we drill down, sugar is a deeply consequential pathway to obesity, (...) and the single greatest dietary source is sugar-sweetened beverages. The copious amount of sugar in the American diet is no accident. Industry practices and regulatory failures have fueled this explosion. Yet there are sensible, effective interventions that would create the conditions for healthier behaviors. What are the key interventions, and how can we overcome the social, political, and constitutional roadblocks? Tobacco control offers a powerful model, suggesting that success requires a suite of interventions working in concert: labeling, warnings, taxation, portion sizes, product formulation, marketing restrictions, and bans in high-risk settings such as schools and hospitals. Each intervention deserves detailed analysis, but I'm kick-starting scholarly and policy conversation by systematically laying out the major legal tools. (shrink)

On March 23, 2010, President Obama signed into law the nation's first comprehensive health care reform bill, the Patient Protection and Affordable Care Act. Within weeks, twenty states filed lawsuits challenging the constitutionality of its most politically charged feature—an individual purchase mandate. By 2014, the bill requires most individuals to have health insurance. With certain exceptions (pertaining to income level and religious objections), individuals without qualifying coverage will pay an annual tax penalty. If anything, the tax penalty is too low (...) compared with the cost of insurance, so it may not provide sufficient incentive for healthy individuals to purchase insurance. But it remains controversial because it compels people to purchase coverage they choose not to have, raising the question whether Congress can lawfully and ethically require individuals to contract with, and transfer money to, a private party. (shrink)

Following from sweeping law reforms across the global health landscape, there is a need to prepare the next generation to advance global health law to ensure justice for a healthier world. Educational programs across disciplines have increasingly incorporated the field of global health law, with new courses examining the law and policy frameworks that apply to the new set of public health threats, non-state actors, and regulatory instruments that structure global health. Such interdisciplinary training must be expanded throughout the world (...) to prepare future practitioners to strengthen global health law — ensuring a foundation for global health in legal studies and law and global health studies. Meeting this imperative for global health law teaching — establishing academic courses and textbooks on global legal responses to shared health threats — will be necessary to support students to address the global health challenges of the future. (shrink)

A single defining question perennially intrigues scholars and practitioners interested in public heath: To what extent should human rights be limited to protect the community’s health and safety? The question achieved prominence in the aftermath of the attacks on the World Trade Center and Pentagon on September 11, 2001 and with the intentional dispersal of anthrax spores through the U.S. Postal Systein. The conflict between security and public health intensified with the development of the Model State Emergency Health Powers Act, (...) drafted by the Center for Law and the Public’s Health at the request of the Centers for Disease Control and Prevention. The Model Act grants states consiclernble powers to control persons and property in response to a public health emergency, defined to inclucle bioterrorism or the appearance of novel or previously controlled or eradicated infectious agents or biological toxins. (shrink)