Public Health Leadership Society ©
2002
Principles of the Ethical Practice of Public Health
Public Health
Leadership Society
Principles of the Ethical Practice of Public Health
Version 2.2
Table of Contents
Component Page
Preamble 1
Values and Beliefs Underlying the Code 2
Principles of the Ethical Practice of Public Health 4
Supplemental Materials:
Rationale for a Public Health Code of Ethics 5
Notes on the Individual Ethical Principles 7
Correspondence of the 12 Ethical Principles 9
with the 10 Essential Public Health Services
Contact for Further Information and Feedback 10
Acknowlegements 11
©2002 Public Health Leadership Society
Table of Contents
Preamble
This code of ethics states key principles of the ethical practice of public
health. An
accompanying statement lists the key values and beliefs inherent to a public
health perspective
upon which the Ethical Principles are based. Public health is understood within
these
principles as what we, as a society, do collectively to assure the conditions
for people to be
healthy. We affirm the World Health Organization’s understanding of health as a
state of
complete physical, mental, and social well-being, and not merely the absence of
disease
or infirmity.1
The Code is neither a new nor an exhaustive system of health ethics. Rather, it
highlights the ethical principles that follow from the distinctive
characteristics of public
health. A key belief worth highlighting, and which underlies several of the
Ethical
Principles, is the interdependence of people. This interdependence is the
essence of
community. Public health not only seeks to assure the health of whole
communities
but also recognizes that the health of individuals is tied to their life in the
community.
The Code is intended principally for public and other institutions in the
United
States that have an explicit public health mission. Institutions and
individuals that are outside
of traditional public health, but recognize the effects of their work on the
health of the
community, may also find the Code relevant and useful.
1 From The Future of Public Health, Institute of Medicine, 1988.
Principles of the Ethical Practice of Public Health, Version 2.2
© 2002 Public Health Leadership Society 1
Values and Beliefs Underlying the Code
The following values and beliefs are key assumptions inherent to a public
health perspective. They
underlie the 12 Principles of the Ethical Practice of Public Health.
Health
1. Humans have a right to the resources necessary for health. The Public Health
Code of Ethics
affirms Article 25 of the Universal Declaration of Human Rights, which states
in part
“Everyone has the right to a standard of living adequate for the health and
well-being of
himself and his family…”
Community
2. Humans are inherently social and interdependent. Humans look to each other
for companionship
in friendships, families, and community; and rely upon one another for safety
and survival.
Positive relationships among individuals and positive collaborations among
institutions are
signs of a healthy community. The rightful concern for the physical
individuality of humans
and one’s right to make decisions for oneself must be balanced against the fact
that each person’s
actions affect other people.
3. The effectiveness of institutions depends heavily on the public’s trust.
Factors that contribute to
trust in an institution include the following actions on the part of the
institution: communication;
truth telling; transparency (i.e., not concealing information); accountability;
reliability;
and reciprocity. One critical form of reciprocity and communication is
listening to as well as
speaking with the community.
4. Collaboration is a key element to public health. The public health
infrastructure of a society is
composed of a wide variety of agencies and professional disciplines. To be
effective, they
must work together well. Moreover, new collaborations will be needed to rise to
new public
health challenges.
5. People and their physical environment are interdependent. People depend upon
the resources of
their natural and constructed environments for life itself. A damaged or
unbalanced natural
environment, and a constructed environment of poor design or in poor condition,
will have an
adverse effect on the health of people. Conversely, people can have a profound
effect on their
natural environment through consumption of resources and generation of waste.
6. Each person in a community should have an opportunity to contribute to
public discourse.
Contributions to discourse may occur through a direct or a representative
system of government.
In the process of developing and evaluating policy, it is important to discern
whether all who
would like to contribute to the discussion have an opportunity to do so, even
though expressing
a concern does not mean that it will necessarily be addressed in the final
policy.
Principles of the Ethical Practice of Public Health, Version 2.2
© 2002 Public Health Leadership Society 2
7. Identifying and promoting the fundamental requirements for health in a
community are of primary
concern to public health. The way in which a society is structured is reflected
in the health of a
community. The primary concern of public health is with these underlying
structural aspects.
While some important public health programs are curative in nature, the field
as a whole must
never lose sight of underlying causes and prevention. Because fundamental
social structures
affect many aspects of health, addressing the fundamental causes rather than
more proximal
causes is more truly preventive.
Bases for Action
8. Knowledge is important and powerful. We are to seek to improve our
understanding of health
and the means of protecting it through research and the accumulation of
knowledge. Once
obtained, there is a moral obligation in some instances to share what is known.
For example,
active and informed participation in policy-making processes requires access to
relevant information.
In other instances, such as information provided in confidence, there is an
obligation
to protect information.
9. Science is the basis for much of our public health knowledge. The scientific
method provides a relatively
objective means of identifying the factors necessary for health in a
population, and for
evaluating policies and programs to protect and promote health. The full range
of scientific
tools, including both quantitative and qualitative methods, and collaboration
among the sciences
is needed.
10. People are responsible to act on the basis of what they know. Knowledge is
not morally neutral and
often demands action. Moreover, information is not to be gathered for idle
interest. Public
health should seek to translate available information into timely action. Often,
the action
required is research to fill in the gaps of what we don’t know.
11. Action is not based on information alone. In many instances, action is
required in the absence of
all the information one would like. In other instances, policies are demanded
by the fundamental
value and dignity of each human being, even if implementing them is not
calculated to be
optimally efficient or cost-beneficial. In both of these situations, values
inform the application
of information or the action in the absence of information.
Principles of the Ethical Practice of Public Health, Version 2.2
© 2002 Public Health Leadership Society
Values and Beliefs Underlying the Code
3
Principles of the Ethical
Practice of Public Health
1. Public health should address principally the fundamental causes of disease
and requirements for
health, aiming to prevent adverse health outcomes.
2. Public health should achieve community health in a way that respects the
rights of individuals in
the community.
3. Public health policies, programs, and priorities should be developed and
evaluated through
processes that ensure an opportunity for input from community members.
4. Public health should advocate and work for the empowerment of
disenfranchised community members,
aiming to ensure that the basic resources and conditions necessary for health
are accessible to all.
5. Public health should seek the information needed to implement effective
policies and programs
that protect and promote health.
6. Public health institutions should provide communities with the information
they have that is
needed for decisions on policies or programs and should obtain the community’s
consent for
their implementation.
7. Public health institutions should act in a timely manner on the information
they have within the
resources and the mandate given to them by the public.
8. Public health programs and policies should incorporate a variety of
approaches that anticipate
and respect diverse values, beliefs, and cultures in the community.
9. Public health programs and policies should be implemented in a manner that
most enhances the
physical and social environment.
10. Public health institutions should protect the confidentiality of
information that can bring harm
to an individual or community if made public. Exceptions must be justified on
the basis of the
high likelihood of significant harm to the individual or others.
11. Public health institutions should ensure the professional competence of
their employees.
12. Public health institutions and their employees should engage in
collaborations and affiliations in
ways that build the public’s trust and the institution’s effectiveness.
Principles of the Ethical Practice of Public Health, Version 2.2
© 2002 Public Health Leadership Society 4
The mandate to assure and protect the health of the public is an inherently
moral one. It carries
with it an obligation to care for the well being of others and it implies the
possession of an element
of power in order to carry out the mandate. The need to exercise power to
ensure health and at the
same time to avoid the potential abuses of power are at the crux of public
health ethics.
Until recently, the ethical nature of public health has been implicitly assumed
rather than explicitly
stated. Increasingly, however, society is demanding explicit attention to
ethics. This demand arises
from: technological advances that create new possibilities, and with them, new
ethical dilemmas;
new challenges to health such as the advent of human immunodeficiency virus;
abuses of power,
such as the Tuskegee study of syphilis; and an increasingly pluralistic society
in which we can no
longer simply adopt the values from a single culture or religion, but we must
work out our common
values in the midst of diversity.
Historically, medical institutions have been more explicit about the ethical
elements of their practice
than have public health institutions. The concerns of public health are not
fully consonant with
those of medicine, however, thus we cannot simply translate the principles of
medical ethics to public
health. For example, in contrast to medicine, public health is concerned more
with populations
than with individuals, and more with prevention than with cure. Thus, the
purview of public health
includes those who are not presently ill, and for whom the risks and benefits
of medical care are not
immediately relevant.
What does a code of ethics accomplish?
A code of ethics for public health clarifies the distinctive elements of public
health and the ethical
principles that follow from or respond to those distinct aspects. It makes
clear to populations and
communities the ideals of the public health institutions that serve them. A
code of ethics thus serves
as a goal to guide public health institutions and practitioners and as a
standard to which they can be
held accountable.
Codes of ethics are typically relatively brief; they are not designed to
provide a means of untangling
convoluted ethical issues. That process requires deliberation and debate over
the multitude of factors
relevant to a particular issue. Nor does a code typically provide a means of
resolving a particular dispute.
It does, however, provide those in a dispute over a public health concern with
a list of issues
and principles that should be considered in the dispute.
Principles of the Ethical Practice of Public Health, Version 2.2
© 2002 Public Health Leadership Society
Rationale for a Public Health Code of Ethics
5
A living document
Many public health professionals, most of them associated with the Public
Health Leadership
Society (PHLS), came together to initiate the process of writing the Code.
Represented on the
PHLS Public Health Code of Ethics Committee are public health professionals
from local and state
public health, public health academia, the Centers for Disease Control and
Prevention (CDC), and
the American Public Health Association (APHA). They were formally encouraged in
this effort during
a town hall meeting attended by representatives from a wide variety of public
health organizations
at the 2000 APHA annual meeting. A draft code was reviewed and critiqued in May
2001 by
25 public health professionals and ethicists in a CDC-funded meeting held in
Kansas City. A
revised version of the Code was presented for discussion at another town hall
meeting at the 2001
APHA annual meeting. Prior to the meeting, the Code was published on the APHA
Website and an
e-mail address was provided for reactions and feedback. The present code
reflects the input and discussion
from all of these forums. It is now being presented to various organizations for
adoption or
endorsement. Even so, there are ongoing opportunities to provide feedback (see
page 10 for details),
and an updating of the Code is anticipated. Tools for teaching about the Code
and ensuring its
practical utility are currently in the making.
Principles of the Ethical Practice of Public Health, Version 2.2
© 2002 Public Health Leadership Society
Rationale for a Public Health Code of Ethics
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Notes on the Individual Ethical Principles
1. This Principle gives priority not only to prevention of disease or promotion
of health, but also
at the most fundamental levels. Yet the principle acknowledges that public
health will also concern
itself with some immediate causes and some curative roles. For example, the
treatment of
curable infections is important to the prevention of transmission of infection
to others. The
term “public health” is used here and elsewhere in the Code to represent the
entire field of public
health, including but not limited to government institutions and schools of
public health.
2. This Principle identifies the common need in public health to weigh the
concerns of both the
individual and the community. There is no ethical principle that can provide a
solution to this
perennial tension in public health. We can highlight, however, that the
interest of the community
is part of the equation, and for public health it is the starting place in the
equation; it is the
primary interest of public health. Still, there remains the need to pay
attention to the rights of
individuals when exercising the police powers of public health.
3. A process for input can be direct or representative. In either case, it
involves processes that work
to establish a consensus. While democratic processes can be cumbersome, once a
policy is established,
public health institutions have the mandate to respond quickly to urgent
situations.
Input from the community should not end once a policy or program is
implemented. There
remains a need for the community to evaluate whether the institution is
implementing the program
as planned and whether it is having the intended effect. The ability for the
public to provide
this input and sense that it is being heard is critical in the development and
maintenance of
public trust in the institution.
4. This Principle speaks to two issues: ensuring that all in a community have a
voice; and
underscoring that public health has a particular interest in those members of a
community
that are underserved or marginalized. While a society cannot provide resources
for health at
a level enjoyed by the wealthy, it can ensure a decent minimum standard of
resources. The
Code cannot prescribe action when it comes to ensuring the health of those who
are marginalized
because of illegal behaviors. It can only underscore the principle of ensuring
the
resources necessary for health to all. Each institution must decide for itself
what risks it will
take to achieve that.
5. This Principle is a mandate to seek information to inform actions. The
importance of information
to evaluate programs is also implied.
Principles of the Ethical Practice of Public Health, Version 2.2
© 2002 Public Health Leadership Society 7
Notes on the Individual Ethical Principles
6. This Principle is linked to the third one about democratic processes. Such
processes depend
upon an informed community. The information obtained by public health
institutions is to be
considered public property and made available to the public. This statement is
also the community-
level corollary of the individual-level ethical principle of informed consent.
Particularly
when a program has not been duly developed with evaluation, the community
should be
informed of the potential risks and benefits, and implementation of the program
should be
premised on the consent of the community (though this principle does not
specify how that
consent should be obtained).
7. Public health is active rather than passive, and information is not to be
gathered for idle interest.
Yet the ability to act is conditioned by available resources and opportunities,
and by competing
needs. Moreover, the ability to respond to urgent situations depends on having
established a
mandate to do so through the democratic processes of Ethical Principle number
three.
8. Public health programs should have built into them a flexibility that anticipates
diversity in
those needs and perspectives having a significant impact on the effectiveness
of the program.
Types of diversity, such as culture and gender, were intentionally not
mentioned. Any list would
be arbitrary and inadequate.
9. This Principle stems from the assumptions of interdependence among people,
and between people
and their physical environment. It is like the ethical principle from medicine,
“do no harm,”
but it is worded in a positive way.
10. This statement begs the question of which information needs to be protected
and what the criteria
are for making the information public. The aims of this statement are modest:
to state
explicitly the responsibility inherent to the “possession” of information. It
is the complement to
Ethical Principles 6 and 7, about acting on and sharing information.
11. The criteria for professional competence would have to be specified by
individual professions,
such as epidemiology and health education.
12. This statement underscores the collaborative nature of public health while
also stating in a positive
way the need to avoid any conflicts of interest that would undermine the trust
of the public
or the effectiveness of a program.
Principles of the Ethical Practice of Public Health, Version 2.2
© 2002 Public Health Leadership Society 8
Correspondence of the 12 Ethical Principles
with the 10 Essential Public Health Services
2 Developed by the Essential Public Health Services Work Group of the Public
Health Functions Steering Committee, 1994.
Principles of the Ethical Practice of Public Health, Version 2.2
© 2002 Public Health Leadership Society 9
Essential Public Health Services 2 Ethical Principle
1. Monitor the health status to identify
community health problems
(5) collect information
(7) act on information
2. Diagnose and investigate health problems
and health hazards in the community
(5) collect information
3. Inform, educate, and empower people
about health issues
(4) advocacy and empowerment
(6) provide information
4. Mobilize community partnerships to
identify and solve health problems
(12) collaboration
5. Develop policies and plans that support
individual and community health efforts
(1) protect and promote health; address
fundamental causes of health risks
(3) processes for community input
(5) collect information
6. Enforce laws and regulations that protect
health and ensure safety
(2) achieve community health with respect for
individual rights
(3) feedback from the community
(7) act upon information
7. Link people to needed personal health
services and assure the provision of health
care when otherwise unavailable
(4) advocate for and empower; basic resources
available to all
(8) incorporate diversity
8. Assure a competent public health and
personal health care workforce
(11) professional competence
9. Evaluate effectiveness, accessibility, and
quality of personal and population-based
health services
(3) community feedback
(5) collect information
10. Research for new insights and innovative
solutions to health problems
(5) collect information
No corresponding essential public health
service
(9) enhance physical and social environments
(10) protect confidentiality
Principles of the Ethical Practice of Public Health, Version 2.2
© 2002 Public Health Leadership Society
Contact for Further Information and Feedback
Visit www.phls.org for:
• Ways to provide feedback to inform ongoing development of the
12 Ethical Principles
• Information on aligning your organization’s public health practice with the
12 Ethical Principles
• Permission to reprint the 12 Ethical Principles and supporting documentation
• Requests for further information about public health ethics or the Public
Health
Leadership Society
• Public Health Leadership Society contact information
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Principles of the Ethical Practice of Public Health, Version 2.2
© 2002 Public Health Leadership Society
Acknowledgements
The development and dissemination of the Principles of the Ethical Practice of
Public Health is
funded by a cooperative agreement between the Centers for Disease Control and
Prevention and the
Public Health Leadership Society (PHLS). The Center for Health Leadership &
Practice, Public
Health Institute is acknowledged for its role in the initial development of the
Principles. PHLS also
acknowledges the work of the members of the original PHLS Ethics Work Group
(responsible for
drafting the Code) and the current members of the PHLS standing Committee on
Public Health
Ethics. Specifically, PHLS acknowledges the following contributors: Elizabeth
Bancroft (Centers for
Disease Control and Prevention, Los Angeles County), Terry Brandenburg (West
Allis Health
Department), Kitty Hsu Dana (American Public Health Association), Jack
Dillenberg (Arizona
School of Health Sciences), Joxel Garcia (Connecticut Department of Health),
Kathleen
Gensheimer (Maine Department of Health), V. James Guillory (University of
Health Sciences,
Kansas City, MO), George Hardy (Association of State and Territorial Health
Officers), Joseph
Kimbrell (Louisiana Public Health Institute and National Network of Public
Heath Institutes),
Teresa Long (Columbus , OH, Department of Health), Alan Melnick (Oregon Health
and Science
University, School of Medicine), Susan Myers (University of Pittsburgh), Ann
Peterson (Virginia
Department of Health), Michael Sage (Centers for Disease Control and
Prevention), Margaret
Schmelzer (Wisconsin Department of Health and Family Services), Liz Schwarte
(Center for Health
Leadership & Practice, Public Health Institute), James Thomas (University
of North Carolina),
Kathy Vincent (Alabama Health Department), and Carol Woltring (Center for
Health Leadership
and Practice, Public Health Institute).
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