Ethics in Public Health

Over the years the concept of so-called individual or “private” health has been included within the broader concept of “public” health, i.e. we have gradually moved from strictly individual health to the “treatment” applied to the whole population.

Analysing the ethical aspects in the context of public health means “touching on” some potentially very different aspects. In fact, we can talk about ethical aspects linked to immigration, advance directives, the protection of the rights of the persons concerned, rights such as information, consent, health and life.

Essentially this means applying the principles of bioethics in the context of public health in a broader sense, i.e. as a public social asset. In fact, if bioethics are understood as “the systematic study of the moral dimensions – including moral vision, decisions, conduct, and policies – of the life sciences and health care, employing a variety of ethical methodologies in an interdisciplinary setting” as Reich wrote in The Encyclopaedia of Bioethics (1995), it can be deduced that it is not an autonomous and independent discipline: it encompasses issues linked to the advancement of knowledge and biological techniques; it must therefore be interdisciplinary. ¹

Some have argued that “with regard to the needs to be protected tradition essentially identifies them as the aspiration to be healthy and efficient, to be adequately assisted in illness, to be alleviated from pain. But recent scientific and technological advances allow us to include the desire for parenthood, even achieved artificially, or a change of sex. The predetermination of children's gender, the replacement of inefficient organs, genetic protection from diseases…” making us ask ourselves: … is it necessary, in principle, to recognise the existence of a positive functional relationship between the biomedical needs to be protected and the scientific-technical possibility of meeting them?”. ²

In fact, the progress and the expansion of knowledge in the scientific field has led to new moral problems arising from new facts, leading us to ask ourselves whether what is technically possible is also ethically correct and how impressive the impact that new technologies can have on public health sometimes appear, considering not only the dimension of the present, but also the future.

The Ottawa Charter (1986) states that “health is therefore perceived as a resource for daily life … it is a positive concept that values social and individual resources, such as physical ability. Thus, health promotion is not only linked to the health sector: it transcends lifestyles to aim towards well-being…

In the context of bioethics, the essential reference point appears to be that relating to the general principles of bioethics.

The principle of autonomy in fact provides that the individual is respected in its autonomy, its right to have opinions, to make choices, promoting the autonomy of the various persons involved in the care process; the principle of non-maleficence that comprises the Hippocratic principle of “primum non nocere”, which affirms the duty to not intentionally cause harm; the principle of beneficence, which is the positive version of the principle of nonmaleficence, and is aimed at preventing or removing harm and promoting the wellness of the person, the principle of justice that emphasises the importance of fairness and justice in medical practice and introduces the socio-economic dimension. As emphasised by the Ottawa Charter “Health promotion aims towards equity in health. Its actions have the purpose of reducing the existing differences that characterise the level of health and offer all individuals the same opportunities and the same means to realise their full health potential. The same Charter indicates that in order to promote Health it is necessary to draw up a public policy for health; create favourable environments; reinforce the community economy; develop personal attitudes; reorient health services.

In Italy the National Committee for Bioethics (Comitato Nazionale per la Bioetica) ³ drew up a document in 2014 entitled “Lifestyles and health protection” which emphasises that “the maintenance of “possible health” depends on resources such as education, working conditions and living situations, the healthiness of the environment, individuals’ behaviours and choices.” It focuses on individual choices, “highlighting and encouraging the responsibility of each person toward their health from two perspectives. The first is that of responsibility toward oneself: health is one of the conditions to be able to fully express one's own personality and preventing the portion of health risk factors attributable to modifiable individual behaviour produces a personal advantage, also in terms of saving oneself from suffering. The second perspective is that of collective responsibility: in conditions of limited resources, the maintenance of an efficient health service directed towards the greatest possible number of citizens is in the interest of all citizens and must therefore be able to count on the personal commitment of the individual to contribute, as much as possible, to maintaining their own health.

Moreover, most modern societies have developed an attitude to moral dialogue in respect of the various positions, still prioritising the fundamental values for man.

The specific problems must be considered in a global context ranging from strictly healthcare dominance to environmental, from the impact of new technologies on individual health to veritable involvement in public health, from issues of the beginning and end of life, to the topics relating to the experimental sphere and then the issues of environmental ethics.

Already in 1999 Barni ⁴ spoke of new protection models and of “conflict between the medical-deontological model and the teleological- utilitarian model in health protection”, stating that “the autonomy of the patient cannot compete beyond a certain limit with the professionalism and understanding of the doctor, the power of the doctor may not …overpower the autonomy of the patient, to conclude that “biolaw, bioethics, deontology, health care ethics” are therefore categories overloaded with dynamic contradictions but able to be governed…”.