Stanford Fall Prevention Program

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Consider enrolling in a fall prevention program that may address some or all of these topics. Consider talking a fall prevention program! Check out our list of fall prevention programs in Northern and Central California. Many fall prevention programs are at hospitals or senior centers. Other good resources are listed below. November 3, 2017 Sexual violence prevention programs continue evolving, expanding. An expanding Beyond Sex Ed program is one of several efforts at Stanford to continue evolving educational. The Administration on Aging (AoA) within the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) forecasts the possible availability of Fiscal Year (FY) 2019 funds to make three-year grants to approximately 10 entities to develop capacity, bring to scale, and sustain evidence-based falls prevention programs that will help to reduce the number of falls. Ellen Corman, manager of Stanford Health Care’s Farewell to Falls program, will be talking about “Fall Prevention in Parkinson’s” at the Menlo Park Parkinson’s Support Group meeting on Wednesday, August 8 th, 2-3:30pm at Little House, 800 Middle Ave., Menlo Park. This event is free and open to the public. Stanford Medicine Tobacco Prevention Toolkit. Fall 2018 Newsletter Newsletter Links Recent Regulations on Tobacco Maine Raises Smoking Age to 21 After Lawmakers Override Veto “The Real Cost” Saves By Reducing Smoking-Related Costs. FDA’s new Youth Tobacco Prevention Plan; Proposition E (San Francisco, CA).

First published Mon Apr 12, 2010; substantive revision Thu Feb 19, 2015

At its core, public health is concerned with promoting and protectingthe health of populations,[1] broadly understood. Collectiveinterventions in service of population health often involve or requiregovernment action. In the United States, for example, the Centers forDisease Control and Prevention, the Food and Drug Administration, theEnvironmental Protection Agency and the Consumer Protection Agency arein part or in whole public health agencies. All nations and moststates or provinces and municipalities have health departments whosefunctions include everything from the inspection of commercial foodservice to the collection and use of epidemiological data forpopulation surveillance of disease. Collective action to promote andprotect population health also occurs at the global level, asexemplified by the activities of the World Health Organization. Publichealth ethics deals primarily with the moral foundations andjustifications for public health, the various ethical challengesraised by limited resources for promoting health, and real orperceived tensions between collective benefits and individualliberty.

One view of public health ethics regards the moral foundation ofpublic health as an injunction to maximize welfare, and thereforehealth as a component of welfare (Powers & Faden 2006). This viewframes the core moral challenge of public health as balancingindividual liberties with the advancement of good health outcomes.Consider, for example, how liberties are treated in governmentpolicies that fluoridate municipal drinking water or compel peoplewith active, infectious tuberculosis to be treated.

An alternative view of public health ethics characterizes the moralfoundation of public health as social justice. While balancingindividuals' liberties with promoting social goods is one area ofconcern, it is embedded within a broader commitment to secure asufficient level of health for all and to narrow unjust inequalities(Powers & Faden, 2006).[2],[3] Thus, another important area of concern isthe balancing of this commitment with the injunction to maximize goodaggregate or collective health outcomes. Understood this way, publichealth ethics has deep moral connections to broader questions ofsocial justice, poverty, and systematic disadvantage.

Against the backdrop of these two normative approaches, this paperproceeds as follows: Section 1 lays out some of the distinctivechallenges of public health ethics. Section 2 discusses differentjustifications for public health interventions, including the role ofpaternalism and how it bears on the permissibility of public healthinterventions. Also discussed in Section 2 are broader questions ofdemocratic legitimacy. Section 3 focuses on questions of justice andfairness in public health ethics. Finally, Section 4 discusses globaljustice as it intersects with public health. Overall, this entrystrives to provide a general lay of the land of the central issuesthat drive public health ethics, with a particular focus on questionsof justice and fairness.[4]

  • 2. Justifying Public Health Programs and Policies

1. Distinctive Challenges of Public Health Ethics

There is no standard way of organizing the ethics of clinicalpractice, public health and biomedical science. These distinctivefields are often presented as focal areas that fall under the broader,umbrella term of bioethics, but sometimes bioethics is presented asthe equivalent of medical ethics or in contrast to public health andpopulation-level bioethics. Whichever approach is preferred, a keyquestion remains: what distinguishes public health ethics from theethics of clinical practice or the ethics of biomedical science? Theanswer lies in the distinctive nature of public health. Public healthhas four characteristics that provide much of the subject matter forpublic health ethics: (1) it is a public or collective good; (2) itspromotion involves a particular focus on prevention; (3) its promotionoften entails government action; and (4) it involves an intrinsicoutcome-orientation.

First, in public health the object of concern is populations, notindividuals. Public health is, by its very nature, a public, communalgood, where the benefits to one person cannot readily be individuatedfrom those to another, though its burdens and benefits often appear tofall unevenly on different sub-groups of the population. This raises aparticular set of justificatory challenges public health ethics has toaddress: who is public health good for? Whose health are we concernedwith, and what sacrifices is it acceptable to ask of individuals inorder to achieve it? Is there a difference between public health andpopulation health? And why is public health a good worth promoting?Any answer to these questions has to take account of the fact thatpublic health measures are often based on prospective benefits,not immediately securable benefits.[5]

Second, promoting public health involves a high degree of commitmentto the prevention of disease and injury. However, although much of thediscussion surrounding public health focuses primarily on thispreventive aspect, public health agencies and services also involvediagnosing and treating illnesses, with all the attendant clinicalservices that those activities require. Indeed, increasingly nationalhealth systems are understood to include both preventive functions andthe delivery of personal medical services. Often, these functions andservices are integrated under a common political or administrativestructure. Depending on the specific context in which populationhealth is to be improved, separating public health services andfunctions from personal medical care services and functions may or maynot make sense. That said, policies and programs whose aim is toprevent illness and injury are paradigmatically the territory ofpublic health. Certainly, no other social institution is generallyrecognized as so clearly having this remit.

Public health's commitment to prevention carries with it particularmoral challenges. Eliminating or mitigating a harm that already existsis sometimes viewed as being of greater moral importance - or simplyas more immediately motivating action - than long-term strategies toprevent a harm from materializing. Although in recent years there isarguably more emphasis on prevention in health policy, preventivepublic health interventions continue to receive less funding andpublic support than medical treatments. For example, despite theincreasing focus on wellness in public policy and theworkplace,[6] bothpolicy makers and the public still tend to place a higher priority onensuring that heart patients have access to surgery and medicationsthan on programs to prevent heart disease through diet andexercise. Another factor that can result in prioritizing cures overprevention is that although the costs and burdens of preventiveinterventions occur largely in the present, the benefits of successfulpreventive interventions often occur in the future, and usually onlyto some members of the population whose identities cannot be predictedin advance and whose numbers can only be estimatedprobabilistically.[7] Thus, prevention policies and programsraise questions about how we should think about statistical andunidentified lives and persons, and whether health gains in the futureshould be treated as worth less than health gains in the present. Insome cases, the beneficiaries of preventive interventions are membersof future generations, complicating the moral picture evenfurther.

Third, as noted previously, achieving good public health resultsfrequently requires government action: many public health measures arecoercive or are otherwise backed by the force of law. Public health isfocused on regulation and public policy, and relies less often onindividual actions and services. In this as in all other areas ofofficial state action, we therefore have to address tensions amongjustice, security, and the scope of legal restrictions andregulations. This adds to the peculiarity of the justificatoryquestions surrounding public health: the exercise of public authorityand the imposition of public sanctions and penalties in an area asdeeply personal as an individual's health choices require strongjustification. The same questions of trade-off between personalfreedom and collective action that arise in the political arenagenerally thus also arise for public health. It is in this contextthat concerns about paternalism typically emerge.

Fourth, public health has a definite consequentialistorientation. Promoting public health means seeking to avoid bad healthoutcomes and advance good ones. As noted at the outset, in somediscussions of public health ethics, this outcome-orientation isviewed as the moral justification and foundation of public health and,as with all consequentialist schemes, is presented as needing to beconstrained by attention to deontological concerns such as rights, andby attention to justice-related concerns such as the fair distributionof burdens (Childress et al. 2002; Kass 2001). While publichealth ethics has to engage with the traditional problems raised byits consequentialist commitments, for those who view social justice asthe moral foundation of public health, considerations of justiceprovide the frame within which the moral implications of publichealth's consequentialist orientation are addressed.

These four distinctive features provide public health ethics with itsbasic structure and orientation. Under the first rubric, importantquestions arise with regard to the scope of public health: who is the“public?” The usual assumption is that the public is adiscrete unit that corresponds with state boundaries: a singlecountry's population. But in a global world, that assumption is notalways plausible for various reasons. Communicable diseases have a wayof ignoring national boundaries, and preventive measures in onecountry may be futile if other countries do not followsuit.[8] Moreover,the statist focus is not always readily justifiable: insofar asdiseases cross borders, should public health interventions do thesame? Further questions about justice and equity across borders alsoarise: do wealthier countries and wealthier individuals haveobligations to attend to the public health of less fortunate others?These questions will be discussed further in section IV, below.

Depending on the particular health challenge we are concerned with,the public in question can be more local or more global than a singlecountry's population. National boundaries are relevant becausepolicies and regulations are usually set by individual countries, andvary from country to country. They are also relevant for reasonshaving to do with government control: countries report their dataabout communicable disease outbreaks, burden of disease, and otherhealth indicators to global institutions such as the World HealthOrganization (WHO) on a voluntary basis. Although International HealthRegulations to which 196 countries (WHO 2014) are signatories providean international structure for global public health, as with muchinternational law and regulation, enforcement mechanisms are weak. Itis not clear what the moral implications of these practicallimitations should be for public health. The structure of the problemis similar to environmental challenges such as air pollution andglobal warming: determinants of ill health are not restricted bynational boundaries, and we are all ultimately connected to eachother's health status, at least in some ways. But more importantly,citizens in the developed world are arguably causally connected tosome health deprivations in the developing world, for example byupholding restrictions on the production and distribution of genericsthat hinder the containment of easily treatable diseases in poorcountries (Pogge 2002; Grover, Citro, Mankad & Lander 2012). Thisgives public health, and therefore public health ethics, a special andvery interesting location vis-à-vis discussions of globaljustice, our duties to the distant poor, and the need for globalcooperation to address common problems (Holland 2007).

Another issue that comes up in this connection is the following: are“public” and “population” interchangeableterms to designate the entity whose health we are concerned with? Isthere a significant conceptual difference, a difference in moralvalence, or a difference in attitude and orientation between publichealth ethics on the one hand, and population-level health ethics onthe other? The literature presents three general ways of denoting theobject of public health: community, the public, and populations. Inone sense, the most morally laden manner of designating those who aresubject to, and benefit from, public health measures, is to thinkabout them as a community (Beauchamp & Steinbock 1999). Referenceto “community” implies a cohesive group, usually with ashared language, culture, history, and geographicallocation. Characterizing the concern of public health as being thehealth of the community renders more natural (and possibly moreplausible) appeal to the common good as a way of justifying publichealth interventions. Reference to “the public” sharessome of those same features but tends to be less morally laden. Thisis in part because “the public” is somewhat more anonymousthan “the community” and does not necessarily signal atight cultural connection. Rather, it connotes a relatively discreteunit with some common institutions and usually a shared politicallife. Thus, references to the public as well as to the community mayencourage the perception that the good we are seeking to advance isthat of a geographically bounded unit, with community connotingstronger cultural associations, and public connoting some kind ofofficial political unit such as a state or a country.

Characterizing the health we are trying to advance as that ofpopulations, by contrast, may minimize the implication that specialshared features or characteristics are needed in order for a group ofindividuals to constitute a collective unit whose health can be ofconcern. Because of that, it may lend itself more readily to aninternationalist, less inward-looking orientation: any population,regardless of nationality or geographic location, has health intereststhat ought to be attended to and advanced (Wikler & Brock2007). Populations can be more local or more global than a communityor the public. This way of speaking also may dilute the emphasis onnational borders as a way of delineating the scope of concern andprovides more flexibility in the object of concern for publichealth. In much the same way, discussion of global health, as opposedto international health, is seen as helpful in emphasizing a focus onthe health needs of all, as opposed to a focus on internationalcooperation and the health needs of peoples in countries other thanone's own.

This is not, of course, to say that those who prefer the term“public health” to “population health” do notshare a global orientation. Indeed, the World Health Organization isgenerally referred to as a global public health institution, and thosewho work to promote health transnationally are referred to as publichealth and not population health professionals. Indeed, although somesee a substantive conceptual divergence in ways of thinking aboutwhose health is to be protected and promoted, others see no conflict,at least between the concepts of public health and populationhealth. For example, the Nuffield Council on Bioethics uses the term“population health” to refer to the collective state ofhealth of members of a population and the term “publichealth” to refer to efforts made to improve the political,regulatory and economic environments that affect prospects forhealth. So understood, the object of public health is the improvementof population health (Nuffield Council on Bioethics 2007, p. XV).

Another conceptual challenge central to public health ethics is how tothink about public health or population health as a public good. Isthe health of the public or of a population a good in its own right,or can it meaningfully be understood only as an aggregation of thewelfare interests secured for each individual that comprises thepopulation? Is public health a good that nations and globalinstitutions can rightly seek with the same justificatory structuresand limitations with which they seek national security and worldpeace, or is it somehow a more limited or different kind of politicalconstruct?

Common to the second, third and fourth features of public health isthe question of how broadly or narrowly to understand what publichealth entails (Powers & Faden 2006). Given a wideningunderstanding of health and the factors affecting prospects forpopulation health, public health can be viewed as being so expansiveas to have no meaningful institutional, disciplinary or socialboundaries. Everything from crime, war and natural disasters; topopulation genetics, environmental hazards, marketing and othercorporate practices; to political oppression, income inequality andindividual behavior has been claimed under the rubric of publichealth. Part of what makes each of these diverse things of concern istheir impact on health, and in that sense they are all public healthproblems. A central role of public health, grounded in social justice,is to bring attention to all aspects of the social or natural worldthat exert a significant impact on the preservation or promotion ofhealth, and not only those that can be effected through traditionalpublic health measures or means.

At the same time, however, health is only one dimension of humanwell-being. Calling attention to the devastating impact on the healthof women of Taliban rule is important, but it should not be confusedwith reducing the injustices of the oppression of women to its healtheffects. The assault of such oppression on personal security,self-determination and respect is of independent moralconcern. Similarly, while reducing violence is critical to populationhealth, that does not mean that law enforcement, the criminal justicesystem, diplomacy and international relations should be consideredtools of public health. Whether and under what conditions it isadvantageous to frame or re-frame a social problem in public healthterms is morally complex. For example, taking a public health ratherthan criminal justice orientation to gun violence or drug abuse cansometimes contribute to defusing tensions, decreasing negativeimpacts on racial or other minority groups, and leading to better overalloutcomes (Dorfman & Wallack 2009).

Because so many of the determinants of the different dimensions ofwell-being overlap and reinforce one another, it is not surprisingthat different social institutions and professional communities sharecommon concerns and priorities, nor should it be expected that publicpolicies rest on only one moral consideration like health orsecurity.

The flip side of this observation is that public health has anobligation to evaluate the impact of its policies and practices onhuman well-being broadly and not only on health. Guaranteed access tobasic health services can improve health, but just as importantly, itcan provide people with a sense of social worth and eliminate theinsecurity of being unable to provide for loved ones in times ofcrisis. Similarly, screening programs for sexually transmittedinfections may improve health but, depending on features of theprograms and the contexts in which they are implemented, they mayresult in social disrespect, decreased personal security andconstraints on personal behavior.

The overlapping of effects and justifications is particularly clear inprevention. Immunization, water fluoridation, anti-smoking campaignsand motorcycle helmet laws are all paradigmatic preventive publichealth interventions. At the same time, however, interventionsgenerally outside the purview of public health institutions andprofessionals such as early childhood education, income supports,literacy initiatives for girls and safe housing programs all can beeffective in preventing illness and injury. In some cases, suchinterventions may be more effective and efficient in achieving healthgains than paradigmatic public health programs. Morally responsiblepublic health policy requires attentiveness to the multipledeterminants of health. This requirement does not signal that publichealth has no boundaries. Rather, public health has a uniquerelationship of stewardship to one dimension of well-being, health,and to the particular determinants that have a special strategicsignificance for health. Some of those determinants are the classicfocus of public health such as infectious disease control and thesecuring of safe food, water, and essential medications. However,exercising that stewardship requires responsiveness to the bestavailable evidence about all the determinants, across the landscape ofan interconnected social structure, that have a special strategicrelation to health, including those outside the conventional remits ofpublic health agencies and authorities. Policies governing education,foreign assistance, agriculture, and the environment can all havesignificant impact on health, just as health policies can have impacton international relations and national and globaleconomies. Providing public health arguments in defense of particularenvironmental or educational policies, and recognizing that suchpolicies can have profound effects on health, simply recognizes thecomplex interweaving of the multiple dimensions of human welfare.

One worry raised by this interconnectedness across spheres of sociallife and policy is that classifying something as a public healthmatter could be an effective way of taking it out of the realm oflegitimate discussion. If the goal of protecting health is seen asclearly good, government actions aimed at securing health may be lessscrutinized than actions aimed at more controversial ends, leavingpublic health officials with too much power and too little democraticaccountability. As a practical matter, however, these concerns may notbe realistic. Although data on this point are hard to come by, it islikely that the reverse is true: public health agencies and workersare more likely to have insufficient political power, authority andresources at their disposal to achieve important and pressing goalsthan to wield too much. It is not usually individuals' civil rights towhich public health interventions stand in opposition, but ratherprivate, corporate economic interests such as the tobacco industry,the meat and dairy industry, and so on. Nonetheless, it is worthraising these worries at least to keep them in view as a possibleissue for public health ethics to address.

Even if the worry that expanding the classification of something as apublic health matter in some way threatens civil liberties is nothingmore than fear-mongering, the breadth of what falls under publichealth may raise concerns about democratic legitimacy. Insofar ashealth authorities have a public mandate to advance health, is ittherefore appropriate for them to hue to strict guidelines as to whatthey can undertake in the name of public health based, at least inpart, on the expressed or revealed preferences or values of thosewithin their reach? Under what conditions are measures such as publichealth surveillance and the banning of certain food materials properlyconsidered to be overreaching by public health authorities, andtherefore to constitute a lack of adherence to theirdemocratically-given mandate? Public health ethics has to give seriousconsideration to the question: how exactly should the mandate ofpublic health authorities be specified such that they do not run afoulof the requirements of legitimacy in a democratic politicalsystem?

Particularly when government institutions are charged with promotingpopulation health, a task of public health ethics is determiningself-imposed limitations and restrictions on what can reasonably comeunder the auspices of public health authorities, for reasons having todo with concerns about individual liberty, about privacy andpaternalism, about democratic process, and about the place of healthin relation to other aspects of human well-being. Thus, public healthethics also has to engage more traditional philosophical questionsabout the scope of privacy, the reach of public policy, and the limitsand legitimacy of government intervention for the public good. Theseissues are addressed next, in Section 2. Moreover, scarcity andpriority setting always loom large in the context of public health,giving rise to a number of equity, justice, and fairness concerns. Asalready noted, these issues are especially acute with regard to globalhealth. Justice and priority setting issues will be addressed ingreater detail in Section 3.

2. Justifying Public Health Programs and Policies

Public health draws its foundational legitimacy from the essential anddirect role that health plays in human flourishing, whether that roleis understood ultimately in terms of maximizing health or of promotinghealth in order to advance social justice. This general justificationis sometimes too broad, however, to provide sufficient moral warrantfor specific public health policies and institutions, especially when,as is so often the case, these policies and institutions areimplemented by the state and affect the liberty or privacy ofcorporate or individual persons. This section puts forward fivejustifications for public health interventions.

Two observations are worth making at the outset. First, public healthpolicies are rarely defended by only one reason. Usually a mixed setof justifications can plausibly be provided. For example, tax policiesintended to decrease cigarette consumption can be defended both byappeal to paternalism and by appeal to reducing the harms of secondhand smoke to children in the home and in automobiles. Second, theimpact of public health policies is often not uniform across all theindividuals affected by the policy, and thus different justificationsare sometimes put forward specific to these different people. Thiscomplexity is unavoidable, since it results from the nature of publichealth: the focus of public health is population health, butpopulations are rarely internally uniform with regard to all featuresthat are morally relevant to any particular policy. Some people maystand to benefit from the policy while others may not. Moreover, inline with concerns about democratic legitimacy and stateover-reaching, some members of the population may support the policywhile others may object. Consider, for example, a New York City policyprohibiting restaurants from serving sugar-sweetened beverages over 16ounces that was eventually struck down by the courts. Public opinionpolling suggests that while more New Yorkers opposed the policy thansupported it, the level of opposition varied from one borough of thecity to another (Grynbaum & Connelly 8/21/2012; New York Times8/21/2012).

The first three justifications for public health policies - overallbenefit, collective action and efficiency, and fairness - speakspecifically to the context in which some members of the affectedpopulation do not directly benefit from the policy or object toit. The next two justifications appeal to the significance of harm,both to others and to oneself. They apply more specifically totraditional concerns about balancing respect for liberty withadvancing health and are more prevalent in the public health ethicsliterature than the previous three. In the fourth justification, theargument is from a relatively uncontroversial Millian harm principle,and in the fifth justification, from somewhat more tendentiouspaternalistic principles.

Depending on the specifics of the public health policy, any number ofthese justifications may be applicable, and they are generally used tobest effect in combination. Section 2 closes with a look at the limitsof frameworks that focus disproportionately on liberty considerationsof the sort addressed in 2.4 and 2.5 and on the importance ofconsidering the range of possible moral justifications in analyzingpublic health policies.

2.1 Overall Benefit

Ultimately, we all benefit from having public health interventions,and from having trusted regulatory agencies such as the Centers forDisease Control and Prevention (CDC) or the Food and DrugAdministration (FDA) make decisions about such interventions and theirreach. All things considered, having public health regulation isbetter than not having it. Public health decisions made on the basisof overall statistics and demographic trends are ultimately better foreach one of us, even if particular interventions may not directlybenefit some of us. Thus, the task of public health ethics is notnecessarily to justify each particular intervention directly. Rather,public health interventions in general, as long as they stay withincertain pre-established parameters, can be justified in the same way amarket economy, the institution of private property, or othersimilarly broad and useful conventions that involve some coerciveaction but also enable individuals to access greater benefits can bejustified: when properly regulated and managed, their existence is byand large better than their absence for everyone. So structured, thejustification for particular public health interventions,requirements, or restrictions is derivative of or parasitic on ahigher level justification.[9] This argumentative strategy has a lot ofappeal, particularly as a way of justifying the existence ofregulatory government agencies such as the FDA or CDC. However, it isultimately insufficient on its own and needs to be supplemented byother kinds of ethical arguments, since it does not provide the basisfor the parameters themselves, or for ethical oversight or scrutinywith regards to the particular decisions such agenciestake.[10]

2.2 Collective Action and Efficiency

A related justification views health as a public good the pursuit ofwhich is not possible without ground rules for coordinated action andnear-universal participation. Thus, public health is viewed as havingthe structure of a coordination or collective efficiency problem. Ifone person (or at least, a sufficient number of such persons) decidesto go when the traffic light is red and stop when the traffic light isgreen, it does not matter that everyone else is following the rules:this person will disrupt the smooth functioning of the system, withpotentially dangerous results. Similarly, if one person (or asufficient critical mass of such persons) decides not to abide by apublic health regulation because the regulation does not directlybenefit her or she otherwise objects, the ramifications will likely befelt by others in her environment andbeyond.[11]Everybody has to participate because, failing their involvement,neither they nor anyone else can reap the benefit of a healthysociety.

In many public health contexts, the only feasible or acceptablyefficient way to implement a policy affects the entire population,leaving no or only very burdensome options open to individualnon-cooperation. Perhaps the most celebrated such example is waterfluoridation, but all safety regulations affecting food and drugsupply and consumer products share this character, as do manyenvironmental and occupational health standards. Here collectiveefficiency considerations loom large. Although we want healthyenvironments and products, individuals are simply not positioned tomake independent decisions about the impact on health and safety oftheir environment and of the hundreds of thousands of productsavailable in the modern market place. Ceding this function togovernment institutions staffed with health experts is prudent andessential to general welfare and social justice in the same respect asceding protection of our interests in personal physical security togovernment institutions staffed with law enforcement and nationaldefense experts is prudent and essential to general welfare (Mill1869).

Collective efficiency arguments rely on claims about the sheer numberand technical complexity of the decisions that need to be made toprotect health in the environment and in the market place, as well asthe indivisible character of responses to some health threats. Thesearguments are buttressed by claims about the cognitive limitations andbounded rationality of individual human decision makers, and by thedisproportionate political power of corporate interests and thepractices they use to manipulate and exploit our cognitive weaknessesagainst our health interests (Ubel 2009).

2.3 Fairness in the Distribution of Burdens

Yet another appeal that can be used to defend certain public healthinterventions that impose unequal burdens on different members of apopulation relies on considerations of fairness. The basic premise ofthis line of argument would be that burdens should be roughlyequivalent for everyone. This justifies taxing different incomebrackets at different rates. The same could be said for certain publichealth “burdens,” understood as both the burdens ofdisease and disability and the burdens of public healthinterventions. Based on considerations such as a particular group'slikelihood to contract a certain disease, and their overall healthstatus, other parts of the population can legitimately be asked to“contribute,” as it were, in order to make thedistribution of disease burdens more equitable. For example, part ofthe rationale for requiring child immunization prior to enrollment inschool is that this is a way to ensure that low-income children, whoare generally less healthy than other children, have access to theneeded vaccines (Orenstein & Hinman 1999; Feudtner & Marcuse2001). Perhaps a more pertinent example is Japan's seasonal influenzaimmunization policy, between 1962 and 1994 where children wereimmunized against influenza explicitly in order to protect theelderly, for whom contracting seasonal flu is more likely to be fatal,and immunization more likely to be burdensome (Reichert etal. 2001; Sugaya 2014). Yet another example of public healthinterventions that appear to be guided by this justification isrubella vaccination of children for the sake of pregnant women andtheir fetuses (Miller et al. 1997; ACIP 2010 in Other InternetResources). This reasoning can help explain why individuals aresometimes asked to bear public health burdens that do not directlybenefit them. However, as with the tax case, the question of how farwe can go in redistributing health-related burdens will likelycontinue to plague any proponent of this justificatorystrategy. Moreover, questions about the plausibility of viewinghealth-related burdens as subject to distribution in this manner mayalso arise.

2.4 The Harm Principle

Likely no classic philosophical work is cited more often in the publichealth ethics literature than John Stuart Mill's essay “OnLiberty” (Mill 1869). In that essay, Mill defends what has cometo be called the harm principle, which has been interpreted as holdingthat the only justification for interfering with the liberty of anindividual, against her will, is to prevent harm to others. The harmprinciple is relied upon to justify various infectious disease controlinterventions including quarantine, isolation, and compulsorytreatment. In liberal democracies, the harm principle is often viewedas the most compelling justification for public health policies thatinterfere with individual liberty. For example, a prominent view inthe United States is that it was not until the public became persuadedof the harmful effects of “second hand smoke” that thefirst significant intrusion into smoking practices—the banningof smoking in public places—became politically possible. Perhapsbecause of the principle's broad persuasiveness, it is not uncommon tosee appeals made about harm to others in less than obviouscontexts. Defenders of compulsory motorcycle helmet laws, for example,argued that the serious head injuries sustained by unprotectedcyclists diverted emergency room personnel and resources, thus harmingother patients (Jones & Bayer 2007). The harm principle has beeninterpreted to include credible threat of significant economic harm toothers as well as physical harm. Returning again to smoking policy,various restrictions on the behavior of smokers have been justified byappeal to the financial burden on the health care system of caring forsmoking-related illnesses.[12]

As with all such principles, questions remain about itsspecification. How significant must the threat of harm be, with regardto both its likelihood and magnitude?[13] Arephysical harms to the health of others to be weighted more thaneconomic harms or other setbacks to interests? Whether interpretednarrowly or broadly, there are limits to the public health cases thatcan plausibly be addressed by the harm principle. Moreover, in thecontext of commitments to social justice and general welfare, and theother justifications described above, too exclusive a focus on theharm principle can undermine otherwise justifiable government mandatesand regulation. It is undeniable that individuals have much broaderand more multi-dimensional interests than narrowly self-directedphysical ones, and in that sense, it is not unreasonable to have afairly expansive understanding of “harm” in a publichealth context. However, adherence to the—admittedly somewhatartificial—heuristic of construing individuals' interests asexclusively their self-regarding ones for purposes of determining whatsacrifices they may be asked to make is an important way of ensuringchecks on potential abuses.

Because the impact of J.S. Mill on public health ethics cannot beoverstated, it is important to recognize that Mill does not hold thatin the formulation of public policies all liberty interests enjoy anequal presumption in their favor. Mill draws a distinction betweeninterests that are so important that they are immune from stateinterference, interests that enjoy a presumption in favor of liberty,and interests that enjoy no such presumption. It is presumably thesecond kind of liberty interest where the harm principle figuresprominently (Powers, Faden and Saghai 2012). Moreover, what manyunderstand to be core to Mill's view, that individuals are generallybest positioned to know what is in their own best interests, isincreasingly being challenged (Conly 2014; Sunstein 2013).

2.5 Paternalism

Not surprisingly, paternalism—understood classically asinterfering with the liberty of action of a person, against her will,to protect or promote her welfare—is as controversial in publichealth policy as the harm principle is uncontroversial (Dworkin 2005;Feinberg 1986). Few public health interventions are justifiedexclusively or even primarily on unmediated, classic paternalisticgrounds, although many more public health programs may havepaternalistic effects. By contrast, other classes of arguments thatare sometimes described as paternalistic, including soft paternalism,weak paternalism, and libertarian paternalism, are evoked morefrequently.

Soft and weak paternalism are usually interpreted as interchangeable,though they have sometimes been taken to denote different concepts(Dworkin 2005). A common interpretation defines this kind ofpaternalism as interferences with choices that are compromised withregard to voluntariness or autonomy. Though a person might voice orhold a preference different from the one that is sought for her, herpreference is not entitled to robust respect if it is formed underconditions that significantly compromise its autonomy orvoluntariness, such as cognitive disability or immaturity and, in verylimited cases, ignorance or falsebeliefs.[14]Adaptive preferences are also considered compromised with regards toautonomy: sometimes, individuals modify their preferences in order tobe able to adapt to difficult, unjust, or undesirablecircumstances.[15] Such preferences also do not have thesame standing as preferences formed under just or normal backgroundconditions and are therefore viewed as subject to interference.

It is important to note that in all these cases, justifiedinterference would be based on a finding of significant compromise of autonomy or rationality in the formation or continued holding ofparticular preferences. This should not be confused with interferencebased on the content of the preferences. Only the former would bejustifiable under soft or weak paternalism, whereas the latter wouldconstitute true or strong paternalism. As always, the demarcations arenot as clear in practice as they are in theory - the content ofpreferences is often precisely what is appealed to in illustratingthat a particular preference is compromised - but by and large, whatdistinguishes soft paternalism from strong paternalism is therequirement that the decision or preference be fundamentallycompromised, and not simply that it be mistaken or ignorant. Thisprincipled distinction remains important not least because it reflectsa difference in approach or attitude: in the case of strongpaternalism, the interference is based on the content of a preferencenot reflecting what is ostensibly in the preference holder'sinterest.[16] Inthe case of soft or weak paternalism, persons might hold all manner ofpreferences not in their best interest that are nonetheless notjustifiably interfered with because the relevant compromisingconditions do not obtain. In public health policy, soft paternalismhas been evoked to justify interventions that limit the ability ofadolescents to act on preferences for alcohol, drugs, sexual activityand driving.

In recent years, public health policy and liberal governments haveincreasingly looked to interventions called 'nudges' to influencehealth behaviors in desirable directions. Nudges, understood typicallyas interventions in choice architecture, are the focus of libertarianpaternalism. Libertarian paternalism defends interventions by planners(such as public health authorities) in the environmental architecturein which individuals decide and act in order to make it easier forpeople to behave in ways that are in their best interests (includingtheir health), provided two conditions are satisfied (Thaler&Sunstein 2003; Thaler & Sunstein 2008). First, individualsare steered by these interventions in ways that make them better off,as judged by themselves. Thus, in libertarian paternalism there is noattempt to contravene the will of individuals, in contrast to whatsome hold to be a necessary feature of paternalism. Second, theinterventions must not overly burden individuals who want to exercisetheir freedom in ways that run counter to welfare. In this sense,libertarian paternalism claims to be liberty-preserving, hencelibertarian.

A key conceptual question about paternalism is whether theinterference with individual liberty must be against the person's will(Beauchamp 2010). If this feature is a necessary condition ofpaternalism, then libertarian paternalism is inappropriatelytitled. From the standpoint of public health ethics, however, whetherlibertarian paternalism is appropriately titled is less important thanany moral issues it raises and how it is justified. There is a growingliterature on the ethics of 'nudges,' much of it focusing on health(Saghai 2013a; Saghai 2013b; Quigley 2013; Hollands et al.2013).

Libertarian paternalism is grounded in the extensive empiricalliterature in cognitive psychology and the decision sciences thatsupport claims about our cognitive limitations, bounded rationalityand weakness of will. Although it raises challenging epistemic andpolitical questions about how planners know what individuals judge isin their interest in specific policy contexts, libertarian paternalismmay be well suited to public health contexts in which there is broadpublic consensus in favor of health-promoting behaviors such as eatingmore fruits and vegetables or getting more exercise, and a generalrecognition that it is difficult for people to act as prudentially asthey would like. Thaler and Sunstein suggest, for example, that saladsrather than French fries could be made the default “side”on restaurant menus, with diners free to request fries if that remainstheir preference. At the same time, libertarian paternalism has beencriticized for failing to take account of the manipulative effects onchoice of some market place forces. It has also been seen as toorestrictive in its conditions (and therefore too weak) to beapplicable or adequate for many public health contexts (NuffieldCouncil on Bioethics 2007; Ubel 2009).

2.6 Liberty-limiting Continua and A Central Task of Public Health Ethics

Part of the appeal of libertarian paternalism in public health policyis that, at least in certain contexts, it appears to sidestep or insome cases resolve the tension between liberty and health. Thistension takes center stage in some analyses of the ethics of publichealth, as when public health policies are placed on autonomy-limitingcontinua and the fourth and fifth justifications dominate theanalysis. An influential such continuum is the Nuffield Council's“intervention ladder” (Nuffield Council on Bioethics2007), which is presented as a way of thinking about the acceptabilityand justification of public health policies. The ladder is anchored atone end by what is presented as the least intrusive option, doingnothing, and at the other end by the what is presented as the mostintrusive option, eliminating choice altogether (as in compulsoryisolation). The Council makes plain that all rungs on the ladder,including doing nothing, require justification and that the ladder isto be taken only as a tool in the moral analysis of public healthpolicies. However, the structure of the ladder and its attendantimagery reinforce the misleading view that balancing individualliberties with achieving health benefits is the primary moralchallenge of public health while at the same time appearing toemphasize ethical concerns about over-reaching the mission of publichealth over ethical concerns about under-serving it.

Continua of this sort also oversimplify the complex impact ofinterventions on choice and liberty and on relations between citizensand the state. Incentives are not always less restrictive of choicethan disincentives, and health promotion campaigns, which aregenerally ranked at or near the least intrusive end of the continuum,are not always without significant moral concern. Ad campaigns thatare transparently sponsored by public health agencies to preventtransmission of influenza by promoting personal infection controlpractices or reduce obesity by encouraging exercise and healthy eatingdo not raise the same moral issues as the embedding of anti-drug orabstinence messages in the story lines of entertainment televisionprogramming by these same authorities (FCC 2000; Forbes 2000 (OtherInternet Resources); Goodman 2006; Krauthammer 2000; Kurtz &Waxman 2000). While the latter poses important questions about respectfor liberty, government over-reaching and democratic legitimacy, thelimited effectiveness of many ad campaigns raises important questionsabout whether the state is under-serving its public healthmission. Moreover, in the case of public health problems like obesity,a reliance on health promotion campaigns and other strategies focusedon influencing the behavior of individuals may fail to placeappropriate burden on the corporate interests and structural socialinequalities that arguably account for much of the problem. Thus,depending on the circumstances, health promotion campaigns may beunjust as well as ineffective (Buchanan 2008; Crawford 1977; Faden1987; McLeroy, Bibeau, Steckler, & Glanz 1988).

An important task of public health ethics is not only to providedifferent moral justifications, but also to critically examine theirrelationship to one another in the context of particular public healthissues and activities so as to ensure a more complete moral picture ofwhat is at stake, and to point out where no sufficient justificationexists. In this way, public health ethics can play a more immediatepractical role in public life: by raising challenges to and providingmoral scrutiny of public health policies, it can contribute tocreating an environment of accountability where both abuses anddeficiencies are less likely. Thus, in addition to its intellectualsignificance, public health ethics can be an important element in thescheme of checks and balances that help keep public health authoritiesfrom overreaching or under-serving their mission.

3. Justice and Fairness in Public Health

Whether social justice is viewed as a side constraint on thebeneficence-based foundation of public health, or as foundational inits own right, there is broad agreement that a commitment to improvingthe health of those who are systematically disadvantaged is asconstitutive of public health as is the commitment to promote healthgenerally (Powers & Faden 2006, Institute of Medicine (USA) 2003;Thomas, Sage, Dillenberg & Guillory 2002; Nuffield Council onBioethics 2007; Kass 2001; Venkatapuram 2011; Gostin 2012).

In this regard, there is an intimate connection between public healthand the field of health and human rights (Mann et al. 1994;Mann 1996; Beyrer et al. 2007; Beyrer & Pizer 2007;Tasioulas & Vayena 2014; Tasioulas & Vayena 2015; Gostin &Friedman 2013). Many in public health accept that there is afundamental right to health, as codified in the United NationsUniversal Declaration of Human Rights or otherwise, although there isless agreement about the justification for such a right or whatprecisely the right entails (General Assembly 1948). A key questionfor public health ethics is on whom the duties generated by a right tohealth fall. Because so many of these duties require collective actionof the sort described in Section 2, governments are obviouscandidates, but so, too, are other social institutions in the privatesector as well as those global in structure that bear on the right tohealth. A failure on the part of these institutions to ensure thesocial conditions necessary to achieve a sufficient level of health isan injustice that on the view of many violates a basic humanright. Note that as a basic human right, the claims of the right tohealth are not in any fundamental respect restricted to nationalborders but rather fall on the human community, as a whole. Thus, aswe discuss later in this section, the extraordinary disparities inlife expectancy, child survival and health that distinguish those wholive in rich and poor countries constitute a profound injustice thatit is the duty of the global community to redress.

Fall Prevention Program For Elderly

One task of public health ethics is to identify which inequalities inhealth are the most egregious and thus which should be given highpriority in public health policy and practice. That the lifeexpectancy of some of world's poorest populations is over twenty-fiveyears less than the life expectancy of those living in some affluentcountries is a clear injustice of particular moral urgency. Not allinequalities are so obviously egregious, however, and differentaccounts of justice and of the relevance of individual responsibilityfor health may yield different conclusions. Different approaches toconceptualizing and measuring health inequalities have differentethical implications (Eyal, Hurst, Norheim & Wikler 2012). On theview that Powers and Faden defend (2006), social justice demands that,insofar as possible, all children achieve a sufficient level ofhealth. Thus, inequalities in the health of children are a particularmoral concern. The health of children is dependent on the decisionsand actions of others and on features of the social structure overwhich children have no control. The value of health to children thusdoes not depend on what children can do for themselves, as itsometimes does for adults. Moreover, the level of well-beingattainable in adulthood is in important respects conditioned by thelevel of health achieved in childhood. Compromised health in childhoodhas profound effects on health in adulthood, as well as on thedevelopment of the cognitive skills necessary for reasoning andself-determination.

When inequalities in health exist between socially dominant andsocially disadvantaged groups, they are all the more important becausethey occur in conjunction with other disparities in well-being andcompound them (Wolff & de-Shalit 2007; Powers & Faden2006). Reducing such inequalities are specific priorities in thepublic health goals of national and international institutions(Department of Health 2009; EuroHealthNet 2014 (Other InternetResources); Healthy People 2020 (2014, in Other Internet Resources);Kettner & Ball 2004; WHO 2015). Whether through processes ofoppression, domination, or subordination, patterns of systematicdisadvantage associated with group membership are invidious andprofoundly unjust. They affect every dimension of well-being,including health. In many contexts, poverty co-travels with thesystematic disadvantage associated with racism, sexism, and otherforms of denigrated group membership. However, even when it does not,the dramatic differential in material resources, social influence andsocial status that is the hallmark of severe poverty brings with itsystematic patterns of disadvantage that can be as difficult to escapeas those experienced by the most oppressed minority groups. Even whenthese patterns are lessened, the life prospects of persons living insevere poverty or in dominated groups often continue to be far belowthat of others. A critical moral function of public health is tovigilantly monitor the health of systematically disadvantaged groupsand intervene to reduce the inequalities so identified as aggressivelyas possible. Keeping obligations to such groups at the forefront ofpublic health thinking can result in significant changes in publichealth policy. For example, which countries should top the list forthe expansion of childhood vaccine programs from low to middle incomecountries can be profoundly affected by how vigilant we are in keepingsystematic disadvantage squarely in mind (Shebaya, Sutherland, Levine& Faden 2010).

One of the most difficult challenges for public health ethics emergeswhen this important moral function conflicts with the injunction toimprove, if not maximize, aggregate or collective healthoutcomes. Although the health of the world's most desperately poor canin many cases be improved by extremely cost-efficient interventionslike basic childhood immunizations and vitamin supplementation,reducing other unjust inequalities in health can consume significantresources. For example, in the United States, infant mortality ratesare higher than in many other wealthy nations, and they are higherstill among poor and minority children. Some state public healthauthorities have made reducing racial disparities in infant mortalitya top priority, accepting the view that redressing this unjustinequality is an urgent moral concern. Other states have chosen thegoal of improving infant survival statistics overall, on grounds thatthe same resources will produce greater aggregate health outcomeswhile at the same time pointing to the special place that all childrenshould hold in public health policy (HRSA 2014 in Other InternetResources).

Still another challenge in social justice for public health ethicsemerges when the health needs of systematically disadvantaged groupsconflict with other dimensions of well-being as well as withconsiderations of collective efficiency. Targeting a public healthprogram to poor and minority communities can sometimes both servesocial justice concerns and be efficient if, for example, the healthproblem the intervention targets occurs disproportionately in thesegroups. At the same time, however, if the health problem is itselfassociated with stigma or shame, targeting the poor and minorities mayreinforce existing invidious stereotypes, thereby undermining anothercritical concern of social justice, equality of social respect. Insuch cases, public health authorities must decide whether a commitmentto social justice requires foregoing an efficient, targeted program infavor of a relatively inefficient, universal program that also mayproduce less improvement in health for the disadvantaged group (thusfailing to narrow unjust inequalities) in order to avoid exacerbatingexisting disrespectful social attitudes.

As noted in Section 2, one of the structural features of public healthis that the individuals and groups affected by its policies andprograms are not uniformly benefited or burdened. When the burdens ofa policy fall heavily on those who are already disadvantaged, thejustificatory hurdle is particularly high. This concern is at theheart of many environmental justice controversies such as the locatingof hazardous waste facilities and hazardous industries in low-incomecommunities and countries. Global efforts to prevent and containpandemic influenzas have also placed significant burdens on theworld's poor. For example, a principal strategy employed to preventavian influenza H5N1 from becoming a human pandemic is the destructionof infected birds and the banning of household poultry in urbansettings. Many families and women affected by this policy relied ontheir backyard poultry as their only disposable source of income andhave been economically devastated as a consequence. Without expressfocus on the interests of disadvantaged people, the moral concernsthis policy raises, particularly in the absence of appropriatecompensation and alternative livelihood opportunities, might well gounnoticed (Bellagio Working Group 2007 in Other Internet Resources;Faden & Karron 2009; Uscher-Pines, Duggan, Garoon, Karron, &Faden 2007).

Public health resources are always in short supply and prioritysetting in public health policy and practice is always morallychallenging. Yet another important set of tasks for public healthethics is working to ensure that considerations of justice areprominent in the setting of public health priorities in health careservices and in prevention and health threat programming(Norheim et al. 2014). In that regard, one focus for publichealth ethics is evaluating the role that formal economic and decisiontheory methods such as cost benefit, cost effectiveness and costutility analysis should play in public health, including thecontinuing examination of the moral assumptions embedded in thesemethods. Formal methods have been used to varying degrees by publichealth authorities in numerous countries in such diverse contexts asdetermining what risks should be regulated in environmental health andinjury prevention policy and in setting priorities for public healthgoals and coverage decisions for health care systems. Embedded inthese methods are morally controversial assumptions. If the discountrate applied to future financial costs and benefits is also applied tofuture health benefits, preventive interventions are disvaluedrelative to interventions whose health benefits occur in the present(Schwappach 2007). Also problematic are “willingness topay” measures as proxies of the value of benefits or riskreduction. Arguably, these measures reify the preferences of theprivileged and fail to provide sufficient moral justification whenrisks materialize (Gafni 1991).

Some formal methods, including most notably cost-utility analysis,rely on what are referred to as summary health measures in whichmortality and diverse morbidities are combined in a single metric suchas a quality-adjusted or disability-adjusted life year. Thesemeasures, and the formal methods that employ them, sometimes rely onassessments of what may be only vague individual preferences fortrade-offs between different states of health or different kinds ofbenefits. Moreover, they make morally problematic assumptionsincluding, for example, whether to differentially value years saved indifferent stages of life and how to disvalue specificdisabilities. Depending on how these and other assumptions aredetermined and specified, summary health measures have been criticizedas being ageist or not ageist enough, as discriminating unfairlyagainst people with disabilities, as failing to capture the moraluniqueness of life-saving, as treating as commensurable qualitativelydifferent losses and benefits, and as failing to take adequate accountof the claims of those who are most disadvantaged (Brock 2002; Daniels2008; Kappel & Sandoe 1992; Nord 2005; Powers & Faden 2006;Ubel 1999; Williams 2001; Whitehead & Ali 2010; Soares 2012).

Because formal methods and summary measures do not reflect these andother considerations of justice, one widely recognized view is thatformal methods should be used solely as aids in public health policyand not as determinative in their own right (Lipscomb, Drummond,Fryback, Gold, & Revicki 2009). That said, there is a powerfulbias in favor of quantification and the empirical in public healthpolicy. Thus, there is the risk that the findings emerging from theseformal analyses will have determinative influence in policycircles. One response to this risk has been to empiricize moralconsiderations by, for example, measuring and aggregating the valuepreferences of the public about moral tradeoffs such as prioritizingby age or life-saving potential (Mason, Baker & Donaldson 2011;Baker et al. 2008; Menzel et al. 1999; Nord1999). These aggregated preferences or other approaches to quantifyingequity considerations can then be used in various ways to structurepolicy guidance. For example, they can be transformed into weightsintended to incorporate moral values directly into the structure ofthe formal methodology, a move that continues to attract considerableinterest (Johri & Norheim 2012) but that is open to criticism onmethodological as well as substantive grounds. Moves of this sort mayobscure controversial moral considerations from public view anddeliberation, undermining democratic values and politicallegitimacy. An important role for public health ethics is to continueto look critically at both the role and specific methods of economicand decision theory strategies for establishing priorities andregulatory standards in public health, recognizing that considerationsof cost-benefit and efficiency are essential to public healthprogramming and policy, and at alternative approaches forincorporating equity considerations in priority setting and regulatorydecision-making (Cookson, Drummond & Weatherly 2009; Global HealthPriorities 2014 (Other Internet Resources); NICE International2014 (Other Internet Resources)).

4. Global Justice

Just as in the economic, environmental, political and security arenas,it has become increasingly difficult to discuss ethical issues in public health withoutconsidering questions of justice, rights and responsibilities beyond borders. What duties do the more fortunate, wealthy, ordeveloped nations owe to promote or protect public health in moreimpoverished, less developed countries or localities? Whatinterventions are justified and how should they be undertaken so asnot to breach respect for national sovereignty? And how should they beundertaken so that they also create lasting improvements in healthinfrastructures abroad, and not just a temporary external solutionthat leaves another vacuum in its wake? The recent outbreak of Ebola in west Africa illustrates both the factuallyinterconnected, global nature of public health and the normativereasons for considering public health a matter of global concern.

Three types of reasons can be advanced in favor of viewing publichealth as transcending national boundaries: self-interest;humanitarian considerations; and justice, rights and duties (Wolff2012). The recent Ebola crisis again provides a helpfulillustration. The most common argument publicly advanced for assisting countries affected by the outbreak is thataddressing the crisis in West Africa is critical to our own health andwell-being in the developed world, as evidenced by the fewwell-publicized cases of Ebola in the United States. Because diseasesare not constrained by national boundaries, we are at risk unless weprovide sufficient resources to contain and eradicate Ebola inAfrica. Thus, we should always consider public health a global matterand should work to shore up health infrastructures and resourcesabroad in order to avoid negative consequences in our ownbackyards.

The next most common reason advanced is a humanitarian one: that weshould provide resources to care for victims of Ebola abroad becauseit would be wrong to stand by and allow others to suffer in a crisiswhen we have the resources to help. Under this framework, we havepositive duties to help those in desperate circumstances, and thosepositive duties can sometimes transcend borders. On this view,anything we do to promote public health abroad is essentially acharitable action.

Far less common in public and academic discussions of Ebola is thethird view: that Ebola-stricken communities have a claim in justiceagainst the world's wealthy countries and persons for the resourcesnecessary to not only contain the current epidemic but also preventfuture ones. Under this view, everyone has a right to health and theresponsibility for the realization of that right crosses nationalboundaries, at least when nations cannot or will not secure it fortheir own citizens. On one of the most compelling arguments for thisview, we all are responsible for institutional structures thatcontribute to and exacerbate unjust global inequalities, includingglobal health inequalities. Consequently, we have a duty to ensurethat the effects of these inequalities are mitigated, by providingresources to resolve crises and also by helping to build effectivepublic health infrastructures in impoverished countries so that crisescan be averted in the future. Failing to do so is an injustice and notmerely a failure to act charitably or in accordance with humanitarianobligations.[17]Ultimately, that is why we cannot escape responsibility forintervening when something like an Ebola outbreak occurs, even ifconcerns about disease transmission and humanitarian sentiments didnot hold sway. One of the most difficult unanswered questions of thisline of reasoning, however, is assignment of responsibility. Who hasthe responsibility to realize the right to health, and how can thatresponsibility be operationalized? This remains a pressing butunder-addressed question in global public health ethics (Millum &Emanuel 2012; Tasioulas & Vayena 2014; Tasioulas & Vayena2015).

As was emphasized in Section 1, public health is and ought to be aboutmuch more than simply medical care and classic public healthinterventions. This observation naturally extends to the internationalarena. Improving the health of the world's poor is indelibly tied toeconomic, social, educational, and environmental improvements as well,and health-related justice claims are also not easily separable fromjustice claims that arise in those other contexts. The mere fact thatthere are people who live in such poverty and deprivation that theyand their children die of starvation and the simplest infection shouldbe a sufficient indicator that there is something seriously wrong withglobal institutional schemes, and that a justice-based obligation toremedy that situation, both from a public health point of view andmore broadly, exists (Pogge 2008). How exactly to characterize and operationalizethat obligation remains the single biggest challenge for public healthethics, and for global justice.

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beneficence, principle of | ethics, biomedical: clinical research | ethics, biomedical: justice, inequality, and health | ethics, biomedical: justice and access to health care | ethics, biomedical: privacy and medicine | justice: international distributive | paternalism

Fall Prevention Program Patients

Acknowledgments

Section 4 draws heavily on Powers & Faden 2006, Chapters 4 and6. We gratefully acknowledge JP Leider, TE Schall, and AA Pridgen fortheir invaluable assistance in preparing this manuscript.

Program

Home Health Fall Prevention Program

Copyright © 2015 by
Ruth Faden<rfaden@jhsph.edu>
Sirine Shebaya<sirine.shebaya@gmail.com>