Ethical Challenges in Public Health Practice and a New Department in Public Health Reports

Never before has the need for ethical discourse in public health been greater in the United States than it is now. The COVID-19 pandemic and the racial reckoning that took center stage in 2020 flooded the public’s consciousness with some of the most challenging ethical questions of our time. Words such as justice, health equity, values, interconnectedness, individual rights, trust, and solidarity crept into every corner of our often contentious national conversation. Public health personnel found themselves in the center of many discussions replete with ethical tensions, managing the urgency of the situation while helping communities identify and address tough ethical questions.

Ethical Challenges in Public Health Practice

The field of public health ethics is a relatively new offshoot of bioethics, with scholarship starting in earnest in the late 1990s and early 2000s. ¹ As the individual focus of clinical ethics became the predominant feature of the field of bioethics, the ethical challenges in public health were not easily addressed by using clinical ethics tools. Public health scholars and practitioners began to develop frameworks that suited the types of value trade-offs that we must make in public health and the decision-making models that address the tensions between the interests of individuals and the needs of the community. ¹ As philosophers and ethicists learned more about the needs of public health, they began to develop the theoretical foundations to analyze the moral questions that public health professionals face. When asked in the 2000s, public health professionals readily reported a number of ethical issues unique to their work, including conflicts related to public–private partnerships, collection and use of public health data, and management of the political relationships between the public health system and other governmental bodies, among others.^2,3

Twenty years on, the digital revolution, numerous pandemics, and an emphasis on equity as the foundation of public health continue to provide public health professionals with a plethora of ethical challenges. Public health interventions pose ethical tensions that must be addressed for successful implementation. Whether using novel data sources for public health surveillance, developing artificial intelligence to advance public health action, considering the role of solidarity in the context of libertarian societies, addressing ethical dimensions of the social determinants of health, mitigating the impact of social and wealth inequity on community health, or embarking on virtually any other public health endeavor, questions about the right thing to do are inevitable. It is essential to identify and address these and other ethical dimensions of public health interventions early and thoroughly for effective uptake. In addition, public health personnel face ethical challenges that can feel personal. The COVID-19 pandemic presented a great deal of moral distress for public health officials, leading many to take a break from public health work or to leave the profession entirely. ⁴

Equipping public health personnel with practical tools to identify and address the ethical dimensions of their work is essential for an effective public health system. ⁵ To ensure that state and local public health agencies are prepared to identify, examine, and address ethical dimensions of their programs and services, the Public Health Accreditation Board—the organization that accredits state and local health departments in the United States—added an accreditation standard in 2013 that requires health departments to identify ethical issues and develop deliberative decision-making strategies to consider and resolve them. ⁶

Much of the early development in the public health ethics literature focused on theoretical development of public health ethics as a separate domain in bioethics. ⁷ While convergence on a single theory has not yet occurred, a convincing case has been made that ethics for public health policy and practice is based on different purposes and principles than ethics for clinical medicine. ¹ A major need now is the translation of the theories of public health ethics into practical tools that allow public health personnel to explicitly add ethical reasoning to all public health decisions. It is this gap in the literature that has led Public Health Reports to create a new department that addresses the ethical dimensions of public health practice.

Ethical Dimensions of Public Health Department in Public Health Reports

To provide an outlet for thoughtful scholarship addressing the role of ethics in public health practice, Public Health Reports is announcing a new regular feature of the journal: Ethical Dimensions of Public Health. It will address practical and applied ethics topics as they relate to the practice of public health. It will be a place for articles that focus on the translation of and interface between public health ethics theory and practice and provide space for all public health personnel to contribute to and benefit from thoughtful discourse related to the everyday ethical challenges that we face in the context of our work.

Consistent with the aims and scope of Public Health Reports, the goal of the new Ethical Dimensions of Public Health department is to publish high-quality articles focused on the ethical practice of public health. We are interested in articles about practical ethics in all public health settings—local, state, national, and global. Articles can be normative or empirical and address any public health ethics topic. Submissions might report ethical dimensions of a particularly challenging situation and its resolution, examine teaching and training ethics across all public health personnel and students, address research ethics associated with epidemiologic research, evaluate ethics decision making in public health, or address new or emerging ethical issues related to the practice of public health. The new department will accept submissions of any type described in instructions for contributors, including original research, commentaries, case studies, topical reviews, brief reports, reports and recommendations, public health evaluations, and public health methodology. In addition, in concert with the goals of our publishing partner, the Association of Schools and Programs of Public Health, we welcome articles that address and provide exemplar programs in ethics training of current and future public health professionals. We encourage broad ethics thinking related to the equity and justice foundations of public health or any of the essential public health services. We look forward to starting the discussion.