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86 journal of law, medicine & ethics

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transmuted or research ethics in the 1940s and 1950sor clinical ethics in the 1960s and 1970s. In the 1980s,the early HIV/AIDS epidemic elucidated the inad-equacy o clinical ethics to address pressing ethicalchallenges that straddled private and public lie. Thisinadequacy led pioneering theorists such as Ronald

Bayer et al.,6 Ruth Faden and Nancy Kass,7 and Law-

rence Gostin and William Curran8 to discuss ways toexpand bioethics in the 1980s to include public healthethical concerns. In 1988, Dan Beauchamp9 oreshad-owed the 2000s by bringing together health, equity,political philosophy, and democratic theory to rootpublic health ethics as a balance o, as opposed to astruggle between, individual reedom and communitywell-being. Recognizing the broader need, scholarsand public health practitioners began to put orwarda variety o specic suggestions or ethical rameworksor public health in the 1990s.

To discuss the ethical ramework o public health,it is critical to understand exactly what public healthencompasses. Public health was dened by the Insti-tute o Medicine in its landmark 1988 publication, The

Future o Public Health,10 as what we, as a society, docollectively to assure the conditions in which peoplecan be healthy. A more delimited denition was pro-ered by John Last in the The Dictionary o Public

Health,11 stating, Public health is an organized activ-ity o society to promote, protect, improve, and, whennecessary, restore the health o individuals, speciedgroups, or the entire population. The American PublicHealth Association outlined the 10 essential unctions

o public health deemed necessary or eective peror-mance (see Table 1).12 With such broad conceptions othe eld, it is not surprising that many approaches andtheories or public health ethics have developed overthe past decade and a hal.

Some have suggested a complete departure rom theclinical ethics approach, while others suggested bor-rowing heavily on the longstanding successul biomed-ical model. The eld o public health ethics continuesto grow with an increasing number o publications on

the topic, a widening array o ideas o how to deal withthe unique ethical needs and eatures o public healthpractice, and the ounding o journals devoted to thetopic o public health ethics (quite separate rom bio-ethics) where these ideas can be exchanged in the peerreviewed literature. Developers o public health ethics

rameworks have outlined the need or models sepa-

rate rom bioethics. Interestingly, new developmentsin bioethics have called or incorporating principleso public health ethics, especially those that recognizethe health needs o the population;13 the merit o plu-ralistic values such as equity, reciprocity, and the com-mon good;14 and evidence-based decision-making.15

The Basics of BioethicsContemporary biomedical ethics, or bioethics, operatesin large part by the practical application o our princi-ples considered in the relationship between the health

care provider and the individual patient. These ourprinciples autonomy, benecence, nonmalecence,and justice were outlined by Tom Beauchamp andJames Childress16 in the 1970s. Although not withoutcritics,17 this principles approach remains the main-stay o hospital ethics committees worldwide. Clinicalbioethicists consider these principles to have primaacie status, which describes an obligation that is tobe ullled unless it conficts with an equal or strongerobligation. Clinicians must identiy the relevant prin-ciples, weigh them against the concerns o a case, andjustiy their clinical decisions and recommendationsbased on the totality o the weighted principles vis-a-

vis the best interest o the patient.During the latter hal o the 20th century, autonomy

became and remains the supreme value in clinical carein the United States and in much o the developedworld. Benecence, or the set o actions intended tobenet others, lost its primacy, and providers wereorced to open their previously unquestioned goodwillto the scrutiny (and sometimes challenge) o inter-ested patients.18 It was no longer enough or a physi-cian to provide a set o instructions, say to take a medi-

In 1988, Dan Beauchamp oreshadowed the 2000s by bringing togetherhealth, equity, political philosophy, and democratic theory to root publichealth ethics as a balance o, as opposed to a struggle between, individual

reedom and community well-being. Recognizing the broader need, scholarsand public health practitioners began to put orward a variety o specic

suggestions or ethical rameworks or public health in the 1990s.

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cation and rest, based on what he elt was best basedon years o training and experience (beneicence).Patients wanted to know what the medication was, itsrisks, i it was the only option, what other treatmentalternatives there were, and oten had suggestions otheir own (autonomy). The perception o autonomy as

the prevailing principle rose rom the convergence o anumber o changes in the social and medical milieu,19but ethical theory continues to hold it inprima acieequivalence with benecence, nonmalecence, andjustice.20

A Review of Selected Suggested Frameworksfor Public Health EthicsHere, 13 public health ethics rameworks are reviewed(see Table 2). These were selected due to their promi-nence in the ield, impact on the development oother theories, or novelty in approach. For purposes

o this paper, I have divided them into two categories:(1) those rameworks that are practice-based, orappear to have developed rom the observations o theneeds o public health practitioners and that cite ewor a mix o philosophical bases; and (2) those that aretheory-based, or appear to have grown rom a specicphilosophy, ethical or otherwise, and attempt to staytrue to that philosophy in applying the ramework topublic health practice, science, and decision-making.I have outlined three specic characteristics o eachramework. First, where applicable, I outline the theo-retical underpinnings that drive the ramework. For

the practice-based rameworks, these underpinningsmight be drawn rom several (or no) schools o ethicalthought. For the theory-based rameworks, there is atleast (and usually) one philosophical approach. Sec-ond, I examine the underlying assumptions, belies, orperspectives upon which the ramework is built; I call

these the oundational values o the ramework. Third,I outline the expectations or actions o the ramework what it is designed to help public health practitio-ners do. I call these the operating principles o theramework. These three ideas might be labeled some-thing other than underpinnings, values, and operat-

ing principles in the original rameworks, but notethe denition o the terms here. Upon review o theprimary rameworks available to date, I will examinethe similarities and gaps in values and principles andanalyze whether the eld is close enough in its think-ing to move toward a convergent approach.

Practice-Based FrameworksPractice-based rameworks or public health ethicsemerged rom the observation that ethical rameworksused in clinical settings were inadequate or resolvingethical dilemmas aced by public health practitioners.

Stemming primarily rom principle-based bioethicsrameworks, these approaches outline oundationalvalues and provide operating principles that direct acourse o thoughtul action (or series o considerations)or practitioners aced with ethical quandaries in thepublic health sphere. Practice-based rameworks donot attempt to provide a comprehensive philosophi-cal approach; however, they do derive in part romimplicit or explicit normative perspectives.

One o the American pioneers o thinking aboutpublic health ethics as a discipline separate rom bio-ethics or research ethics is Nancy Kass o Johns Hop-

kins University. She wrote one o the earliest suggestedethical rameworks or public health, published in theAmerican Journal o Public Health in 2001.21 For therst time, a ramework that ocused on the practicalnature o public health was outlined in a practitionersjournal, aimed at public health proessionals rather

Table 1

American Public Health Association, 10 Essential Public Health Services, 2010,

reprinted from (last visited January 10, 2012).

1. Monitorhealth status to identify community health problems.2. Diagnose and investigatehealth problems and health hazards in the community.

3. Inform, educate, and empowerpeople about health issues.

4. Mobilizecommunity partnerships to identify and solve health problems.

5. Develop policies and plans that support individual and community health efforts.

6. Enforce laws and regulations that protect health and ensure safety.

7. Linkpeople to needed personal health services and assure the provision of health care when otherwise unavailable.

8. Assure a competent public health and personal healthcare workforce.

9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

10.Research for new insights and innovative solutions to health problems.

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than philosophers. Kass, like others beore and aterher, discussed the inadequacy o the bioethics modelto support the needs o public health ethics and pro-posed a ramework (see Table 2) based on two key val-ues rights (both negative and positive) and socialjustice. She described several principles supporting

what she termed a code o restraint balanced withthe airmative obligation to improve the publicshealth and reduce health inequities. The key princi-ples in the ramework include ensuring the minimallevel o intererence to improve population health inorder to preserve the negative rights o the citizenry,identiying and minimizing harms and burdens to themaximum extent possible while not greatly reducingprogram eectiveness, reducing social inequities andhealth disparities, and providing evidence o programbenets. Kass was one o the rst to urge public healthpractitioners to engage in thoughtul ethical analysis

using the ramework in order to make us meticulousin our reasoning, requiring us to advocate interven-tions on the basis o acts and not merely belie.

James Childress et al. (including Kass), attemptedto conceptualize the terrain o public health ethics asit existed in 2002.22 The authors outlined the quintes-sential problem or population medicine as it relatesto clinical medicine. Three concepts o public under-gird their belie that the bioethical model is a poort or public health ethics: the meaning o publicas population; the execution o public health as aninherently governmental activity that must be well-

rooted in moral reasoning expected by the public thatthe government represents; and third, the denitiono public in its broadest sense to include all socialaction, both public and private, that aects health.The authors outlined three goals o public health,including production o benets, prevention o harms,and maximization o utility. The general ethical andmoral considerations or achieving these goals, theystate, [do] not entail a commitment to any particu-lar theory or method. What we describe and proposeis compatible with several approaches. They list theollowing relevant moral considerations or deliberat-ing about and justiying public health actions. Public

health agents must produce benets and prevent andremove harms. They must produce the best possibleutility, that is, the optimal balance o benets overharms. They must ensure air distribution o bur-dens and benets, ensure the publics participation,and respect autonomy in choice and action. Theymust protect individual privacy and condentiality,and keep promises. They must be transparent, thatis, speak truthully, and disclose inormation. Finally,they must build and maintain public trust. All o

these values are consideredprima acie and when oneappears to become more important than another, theauthors oer ve conditions to be used to justiy over-riding one or more o the moral considerations.

In the same year, RossUpshur, a Canadian physi-cian, perormed a literature review and reported the

principles relevant to the ethical justication or pub-lic health interventions published to date.23 Upshurbegan by pointing out the substantive dierencesbetween clinical and public health practice, includ-ing the locus o care as the state versus the clinician,the ocus on the community or population versus theindividual, the lack o an analogous duciary role asthat played by physicians, and the act that popula-tions are diverse and require pluralistic approachesto problem solving. He argued that a set o principlesor public health proessionals might be useul as theyrefect on ethical issues, as the principles are heuristic

in nature and serve to bring clarity to a broad rangeo decisions required in public health practice. Theseprinciples, he argued, would not represent a ull artic-ulation o a theory or public health ethics, rather theywould relate to whether or when a particular publichealth action is justied. The principles are based onempirical observations o the needs o public healthpractitioners and their decision-making via a litera-ture review. Upshur did not make explicit the under-lying values o the principles, but within the descrip-tion o each he intimates the importance o autonomy,nondiscrimination/social justice, social duty, honesty,

and truthulness. The our principles Upshur oundin the literature in the early 2000s included the harmprinciple, the principle o least restrictive or coercivemeans, the reciprocity principle, and the transparencyprinciple. The harm principle, stemming rom the phi-losopher John Stuart Mill, was described by Upshur asthe oundational principle and dictates that the onlyjustication or imposing power over an individualmember o society against his will is to prevent harmto others. The principle o least restrictive or coercivemeans dictates that despite the availability o a varietyo methods to reach a public health goal, the rst usedmust be that which restricts personal liberty the least.

The reciprocity principle states that there is an obliga-tion on the part o the public to comply with publichealth requests once they are warranted and an ethicaldecision or action has been made. Finally, the trans-parency principle requires stakeholder involvementin decision-making, as well as a clear and account-able process that is ree o diversion by groups or per-sons with interering special interests. Upshur calledor integration o ethical reasoning into public health

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Table 2

Public Health Ethics Frameworks, 1996-2010

Author, citation

Philosophical

Underpinning Foundational Value(s) Operating Principle(s)

Practice-based frameworksN. E. Kass, An Ethics Frame-work for Public Health,Ameri-can Journal of Public Health 91, no.11 (2001): 1776-1782.

EmpiricalBioethicsResearch ethics

-Negative right to noninterference-Positive right or obligation to im-prove the publics health

-Social justice

-Minimal interference for improvement ofpopulation health

-Obligation to reduce inequities-Reducing harms & burdens-Providing evidence of benets

J. R. Childress, R. R. Faden, R. D.Gaare, L. O. Gostin, J. Kahn, R. J.Bonnie, N. E. Kass, A. C. Mastroi-anni, J. D. Moreno, and P. Nieburg,Public Health Ethics: Mappingthe Terrain,Journal of Law, Medi-cine & Ethics 30, no. 2 (2002):170-178.

EmpiricalHuman rightsWorks with sev-eral philosophi-cal approaches

-Producing benets-Preventing, removing harms-Producing maximal balance of ben-ets to harms

-Distributing burdens & benets-Ensuring participation-Respecting autonomy-Protecting condentiality-Keeping commitments

-Disclosing information truthfully-Building & maintaining trust

-Effectiveness-Proportionality: benets must outweigh theinfringement

-Necessity: ensuring that any infringement isnecessary

-Least infringement: only the least possibleinfringement on autonomy is justied

-Public justication: transparency & ac-countability require public explanation of

infringement

R. E. G. Upshur, Principles forthe Justication of Public HealthIntervention, Canadian Journalof Public Health 93, no. 2 (2002):101-103.

EmpiricalHeuristicApplicable todiversity of publichealth decisions

Intimated:-Individual liberty-Nondiscrimination-Social duty-Honesty & truthfulness

-Harm principle-Least restrictive or coercive means-Reciprocity principle-Transparency principle

A. K. Thompson, K. Faith, J. L.Gibson, and R. E. G. Upshur,Pandemic Inuenza Prepared-ness: An Ethical Framework toGuide Decision-Making, BMCMedical Ethics 7 (2006): E12.

EmpiricalApplicable topublic healthemergencysituations

-Duty to provide care-Equity-Individual liberty-Privacy-Proportionality-Protection from harm-Reciprocity

-Solidarity-Stewardship-Trust

-Inclusiveness-Openness & transparency-Reasonableness-Responsiveness

N. M. Baum, S. E. Gollust, S. D.Goold, P. D. Jacobson, LookingAhead: Addressing Ethical Chal-lenges in Public Health Practice,Journal of Law, Medicine & Ethics35, no. 4 (2007): 657-667.

Empirical -Population-level utility-Evidence-Justice/fairness-Accountability-Costs/efciencies-Political feasibility-Benecence-Nonmalecence-Autonomy

-Unmask normative assumptions and ethicaltradeoffs explicitly

-Add ethical value to economic analyses-Illuminate and clarify ethical considerationsconnected to policies or program decisions

-Clarify limits of public health mission

G. R. Swain, K. A. Burns, and P.Etkind, Preparedness: MedicalEthics Versus Public Health Eth-ics, Journal of Public Health Man-agement Practice 14, no. 4 (2008):354-357.

Empirical -Interdependence-Community trust-Fundamentality-Justice

From Kasss model (5):-Minimal interference for improvement ofpopulation health

-Obligation to reduce inequities-Reducing harms & burdens-Providing evidence of benetsPlus:-Focus on fundamental causes of disease-Community participation, collaboration, com-munication, and consent

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Author, citation

Philosophical

Underpinning Foundational Value(s) Operating Principle(s)

H. W. Jaffe and T. Hope, Treatingfor the Common Good: A Pro-posed Ethical Framework, PublicHealth Ethics 3, no. 3(2010):193-198.

Empirical -Respect for persons/autonomy-Benecence-Nonmalecence-Justice

-Valid consent procedure-Risk of harm to recipients is low or negligible-Public health benet cannot be produced byalternative means

-Public health benet justies risk to harm toindividuals

-Data on harm collected to increase accuracyof risk and harm estimates

-Intervention is scrutinized by independent body

Theory-Based Frameworks

J. M. Mann, Health and HumanRights, BMJ 312, no. 7036(1996): 924-925.

Human rights -Human rights are critical determi-nants of health

-Basic minimum that governmentsshould ensure for all persons inorder to ensure health

-Health is contextual and more than medicine-Public health practitioners must commit tolinking human rights with public health

M. J. Roberts and M. R. Reich,Ethical Analysis in PublicHealth, The Lancet 359, no. 9311(2002): 1055-1059.

Ethics-of-careFeminismConsequentialism

-Caring relationships are not impar-tial, impersonal, or equal

-Relationships fundamentally unequal-One cannot and should not care

for all humans equally

-Caring roles are important part of life plan-Support for the caring role is important forboth the caregiver and society

B. Jennings, Public Health andCivic Republicanism: Toward anAlternative Framework for Pub-lic Health Ethics, in A. Dawsonand M. Verweij, eds., Ethics, Pre-vention, and Public Health (NewYork: Oxford University Press,2007).

CivicrepublicanismPoliticalphilosophy

-FreedomLife in the absence of arbitrarypower

Relationships of mutuality &reciprocity

-Respect diversity-Civic virtue-Concept of the public

-Tap into latent civic virtue-Education

C. Petrini and S. Gainotti, APersonalist Approach to Public-Health Ethics, Bull World HealthOrganization 86, no. 8 (2008):624-629.

PersonalismUtilitarianismKantian theoriesCommunitarian-ism

-Autonomy-Condentiality-Equity-Equal opportunity for healthresources

-Solidarity and sociality

-Respect for individual rights-Individual good is basis for common good-Cases exist where freedom must be sacri-ced for the common good

-Precaution principle (making temporary deci-sions based on available evidence, modifying

with new evidence)

Nufeld Council on Bioeth-ics, Public Health: Ethical Issues,London: Nufeld Council onBioethics, 2007, available at (last visited Janu-ary 4, 2012).

-Politicalliberalism

-John Stuart Millsclassic harmprinciple

-Collectivism/community-Paternalism/libertarianpaternalism

-Equality between citizens-Protection of individual freedomlimits state authority

-Social contract that state powermay be used to advance welfare

-Autonomy as self-governance-Health is important for a good life-Health is dened by individuals-Limiting liberty is acceptable onlywhen purpose is to prevent harmto others

-Third-party participation in publichealth delivery

-Reduce risks persons impose on each other-Use regulation to ensure environmental con-ditions that sustain good health

-Attend to health of children and vulnerablepersons

-Provide programs that help make it easy forpeople to lead healthy lives

-Ensure access to appropriate medical services-Reduce unfair health inequalities-Do not coerce adults-Minimize interventions that are introducedwithout some form of consent, individual,community or democratic decision-making

-Minimize interventions that are perceived as

intrusive or in conict with important per-sonal values

N. P. Kenny, S. B. Sherwin, andF. E. Baylis, Re-visioning PublicHealth Ethics: A Relational Per-spective, Canadian Journal ofPublic Health 101, no. 3 (2010):9-11.

Relational ethics -Relational autonomy: persons aresocially, politically, and economicallysituated

-Relational social justice: fair accessto social goods (rights, opportuni-ties, power, self-respect)

-Relational solidarity: attending toneeds of all, especially vulnerableand systematically disadvantaged

-Transparency-Fairness-Inclusivity-Interconnectedness-Responsive to systemic inequalities

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decision-making as well as evaluation o the utility othe principles outlined above.

In 2006, ollowing the global SARS epidemic andwhile preparing or pandemic inluenza, Upshurworked with colleagues in Toronto to urther developthe ethical ramework he proposed in 2002. Ali-

son Thompson et al.24 proposed the more developedmodel in the context o pandemic preparedness andbased the applied ethical ramework25 on NormanDanielss ramework o deliberative prioritization inhealth care.26 They outlined ten oundational valuesand ve operating principles that should drive publichealth decision-making, especially in urgent or emer-gent circumstances. The values subsumed those inti-mated in Upshurs earlier ormulation and includedothers that pertain to public health emergencies.

The ten values made explicit in the 2006 rameworkwere the ollowing:

(1) the duty to provide care, which requires healthproessionals to respond to those suering;

(2) equity, which ensures that, all else equal, all per-sons have equal claim to care;

(3) individual liberty, which requires respect orpersonal autonomy and limiting restrictions onindividual liberty to the extent possible;

(4) privacy, which emphasizes the need to respectthe privacy o individuals by allowing disclosureo private identiable inormation only whenthere is no less intrusive means to protect public

health;(5) proportionality, which requires that any restric-tions to liberty do not exceed that which isnecessary to the level o risk or need o thecommunity;

(6) protection rom harm, which is public healthethics oundational principle the obligationto protect the public rom serious harm;

(7) reciprocity, which requires the public to complywith legitimate public health measures to sup-port those who ace a disproportionate burden;

(8) solidarity, which emphasizes the need or sys-tematic collaboration across institutional

boundaries to support public health measures;(9) stewardship, which requires those entrusted

with governance o limited resources to act in atrustworthy and ethical manner; and

(10) trust, which is an overriding component at alllevels o the health system and takes time tobuild with various stakeholders.

The ive operating principles o ethical decision-making outlined in the 2006 ramework included theollowing:

(1) accountability, which requires that a mechanismbe in place to ensure that ethical decision-mak-ing is in place;

(2) inclusiveness, which recommends that decisionsare made with aected stakeholder views underconsideration;

(3) openness and transparency, which means thatall decisions should be deensible and open toscrutiny, as well as actively communicated inadvance to aected stakeholders;

(4) reasonableness, which requires that decisions beevidence-based and that stakeholders agree onwhich principles and values are relevant to thedecisions; and

(5) responsiveness, which allows or opportunitiesto revisit and revise decisions when new inor-mation presents itsel and requires that a or-mal mechanism be devised so stakeholders can

express concerns during the implementation oany process. Strong leadership rom the high-est levels and requent and early engagement ostakeholders are keys to success in implement-ing this ethical decision-making process.

By 2007, the inadequacy o the autonomy-ocusedbioethics approach as applied to the population andcommunity-ocused eld o public health was consid-ered common knowledge in the eld. NancyBaum etal.27 examined this concept and outlined a rameworkto address various ethical challenges aced by public

health practitioners and policymakers. The ounda-tional values included six primary drivers (population-level utility, evidence, justice/airness, accountability,costs/eciencies, and political easibility) and threesecondary drivers (benecence, nonmalecence, andautonomy). The secondary drivers are amiliar in thebioethics ramework, but play a less important rolein public health ethics. The authors outlined severalimportant justications or public health practitio-ners to spend time and eort on ethical claricationand oer their ramework as a tool to assist in thisendeavor. They believe that clariying the ethical oun-dation o practitioners decisions adds value to their

work or a number o reasons, including transparency,or ensuring an unmasking o normative assumptionsand ethical tradeos at stake so persons involved andaected can observe and participate in the discus-sion. Additionally, they suggested that clarication oethical components o decisions helps justiy and bal-ance pure economic analyses. Simply basing decisionson economic beneit shortchanges the public, anda transparent ethical analysis aids with the analysis.The authors also suggested that clariying the ethicalconsiderations related to public health policies helps

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elucidate the limits o public health interventions anddelineates the breadth and scope o public health mis-sion. This, in turn, helps identiy the limits o imposi-tion o public health policy on individual liberty. Theprimary ocus o the ramework was to present a set opractical considerations that can assist public health

practitioners and policymakers in day-to-day practicethat tied more closely public health ethics and publichealth policy.

GeoreySwain et al. returned to the topic o publichealth ethics in the context o preparedness in 2008,reviewing the dierent underlying values o medicaland public health ethics and their application to pub-lic health preparedness.28 The model suggested usingunderlying values based on those outlined by JamesThomas,29 which include interdependence, or achiev-ing health in a way that respects individuals whilerecognizing that health oten depends on others; com-

munity trust, or developing and maintaining trustthrough transparency, condentiality, cultural sensi-tivity, and obtaining community consent or interven-tions; undamentality, or staying ocused on the pri-mary causes o disease in both the physical and socialenvironment; and justice, or ensuring that conditionsor health are equally accessible to all. With these val-ues in mind, the authors suggested the use o Kassssix-point ramework30 (see above) to assess the ethicalimplications o proposed public health actions. Theyadded two additional questions to Kasss six, includingwhether the program ocuses on undamental causes o

disease and whether there has been adequate commu-nity collaboration, participation, and ultimately con-sent. The authors pieced together an approach basedon existing approaches with an emphasis on the needso a community during a public health emergency.

Harold Jae and Tony Hope, like Swain, also pro-posed re-use and adaptation o an existing ethicalramework or public health ethics.31 In response to aspecic proposal to test and treat persons with HIV inorder to reduce transmission to others,32 the authorsdrew parallels to the ethical ramework o medicalresearch based on the act that both research and thisintervention present a situation where a treatment

that might be harmul to the individual yields ben-ets to others. Research participants agree to take onpotential risks in order to move medical science closerto good outcomes or persons other than themselves.In some public health interventions, specically in theone suggested by ReubenGranich et al.33 where initi-ating antiretroviral treatment might not be medicallyindicated or the individual patient, but is required toreduce ones viral load and hence the ability to trans-mit to others, the person involved in the interventiontakes on risk or discomort in order to benet others.

These similarities between research and some com-munity-level HIV interventions led Jae and Hope tooutline a ramework consisting o underlying valuesbased on a number o national and international guid-ance documents (e.g., Belmont Report,34 CIOMS35)and similar to those underlying research ethics; those

values include respect or persons (autonomy), bene-cence, nonmalecence, and justice. The six necessaryoperating principles include (1) ensuring a valid con-sent procedure is in place; (2) ensuring that the risk oharm to individuals is low or negligible (in cases whereparticipants are unable to provide individual consent);(3) arming that the public health benet cannot beproduced by alternative means; (4) arming that thepublic health benet outweighs and justies the risko harm to individuals; (5) collecting additional dataso risk and harm estimates can be improved; and (6)ensuring proper scrutiny o the intervention by an

independent and qualied body. The authors concludethat o the three types o public health interventions those that clearly benet the individual recipients,those that are required to prevent serious harm suchthat coercive measures like laws are put into place, andthose where it is unclear i there is benet to the indi-vidual and there exists the possibility or harm, but thebenet o the greater good is clear it is the latter orwhich their proposed ramework is most appropriate.

Theory-Based FrameworksPrinciple-based rameworks or ethical decision-mak-

ing have been criticized based on claims that they lacka common moral imperative to guide behavior,36 oeronly simple standards or behavior, which are inade-quate or resolving complex ethical problems,37or cre-ate an untenable collection o whatever works rom avariety o philosophical theories.38 These decits, crit-ics argue, leave an unanchored set o mid-level moralprinciples that are open to interpretation; they justiybehavior rather than inorming it. Moral decisionsshould stem rom a uniying, impartial system thatreduces the amount o harm in the world and appliesto all persons equally and publically, including thoseespousing it.39 Developers o rameworks or public

health ethics based on specic philosophical under-pinnings careully describe the undamental uniyingtheoretical basis rom which all ethical decisions canbe derived.40

In the mid-1990s, when the HIV epidemic haddevastated many countries, Jonathan Mann oered ahuman rights ramework as an alternative to the tra-ditional biomedical approach or dealing with mod-ern public health challenges.41 He argued that humanrights are critical determinants o health more sothan clinical medicine in many cases and that gov-

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ernments have an obligation to ensure that all personshave a minimum set o rights in order to ensure health.These oundational values, bolstered by human rightstheory, translate into the operating principle that pub-lic health practitioners must commit to linking humanrights with public health. Further direction on how to

incorporate these ideas into ethical decision-makingduring the practice o public health is lacking, in partdue to Dr. Manns untimely death in 1998.

Challenging three bioethical philosophies utili-tarianism, rights-based theories, and communitari-anism in 2002, MarcRoberts and Michael Reich42outlined an approach to analysis o ethical questions inpublic health that they describe as ethics-o-care em-inism. Ethics-o-care eminism understands caringrelationships as undamentally unequal. Relationshipsare not impartial, impersonal, or equal, which meansthat one cannot care or all persons equally. To change

health policy, the authors argue, amily lie must notbe ignored; amily relationships and responsibilitiesmust be taken seriously and understood as centralto the human experience. More supportive policieswould be developed i an ethics-o-care perspectivewas understood, perhaps by asking policymakers toput themselves in the shoes as every patients mother.The ethics-o-care approach is limited in scope giventhe breadth o public health activities and obligations.It provides the public health practitioner with a spe-cic perspective or approaching policy development,but has not yet oered tools with which a practitioner

can conront ethical dilemmas o daily practice.An early and strong infuence on the philosophi-cal development o the eld o public health ethicsis Bruce Jennings. His most recent treatment o thephilosophical underpinnings o public health ethicsas a separate and distinct eld rom bioethics is heav-ily favored with political philosophy, emphasizing thepolitical and legal oundations o public health. Heproposed a move away rom liberalism toward civicrepublicanism,43 arguing that our oundational val-ues o civic republicanism best serve public health.The rst two values, reedom as lie in the absence oarbitrary power and relationships o mutuality and

reciprocity, respect diversity in our modern day plu-ralistic society and provide a ramework where per-sons can claim equal membership and standing. Theother two oundational values, civic virtue and con-cept o public, point to the common good, citizenship,and creation o the public space. Civic virtue, or a wayo being in the political world in which we all live, isexcellence in citizenship and pursuit o the common,or public, good. Jennings argues or political theoryto undergird public health ethics, as he denes a pub-lic as a durable structure, comprising more than sim-

ply the aggregate o individuals, but a combination oits people, customs, norms, and traditions. The public,then, has shared purposes and shared problems thatare dierent than individual purposes and problemsand need civic orientation or resolution. The ounda-tional values proposed by civic republicanism in the

service o public health ethics might have operatingprinciples or use by public health practitioners. Jen-nings describes tapping into the populations latentcivic virtue and education as eorts that might yielda positive response, but the answer to the question,What should the public health practitioner do? isnot well developed.

Carlo Petrini and Sabina Gainotti44 echo earlierconcerns that public health is too broad or a simpleset o uniying principles such as the our with whichbioethics is amiliar (i.e., Beauchamp and Childresssautonomy, benecence, nonmalecence, and justice45).

Ater arguing convincingly that codes o ethics are rel-evant but inadequate or resolving public health eth-ics dilemmas, the authors consider three oten citedphilosophical theories associated with bio- and publichealth ethics utilitarianism, Kantian theories, andcommunitarianism. Each o these theories is incom-plete in its application to the breadth o public healthand is missing a key concept: a clear denition o theconcept and value o the human person, which playsa primary role in their proposed theory, personalism.As dened by the authors, personalism is based uponour common shared human nature. It takes as its pri-

mary ethical principle that all human beings deserverespect.46 Originating in health ethics and sharingcommon themes with the health and human rightsmovement,47 personalism emphasizes the protectiono the weak and sick, dignity as inalienable, and mea-sures our moral worth as a refection o the well-beingand dignity o others. As such, it obligates us towardpositive eorts. The underlying values associated withpersonalism derive rom respect o the person andinclude autonomy, condentiality, equity, and equalopportunity in the allocation o health resources.Personalism has a blend o communitarianism, in itsvalue o sociality and solidarity, and Rawlsian perspec-

tives, in its belie that the individuals good is the basisor the common good.48 The authors provided littleoperational guidance or implementing the personal-ist approach, but conclude that it is critical to answerphilosophical questions about the value o humanhealth i we are to nd solutions through legislation.

In the United Kingdom in 2007, public health eth-ics was receiving national attention in the orm o theNueld Council on Bioethics (the Council) publish-ing a report, Public Health: Ethical Issues,49 whichoutlined a model or public health ethics called the

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stewardship model. Attentive to an inclusive pro-cess,50 the Council comprised experts in a diverse seto specialties, including medicine, public health, eth-ics, philosophy, economics, social and behavioral sci-ence, pharmacology, and law. The Council consideredmultiple theories while attempting to nd the best set

o ethical underpinnings or public health practice.The process involved nine meetings over 18 monthsincluding act-inding meetings where discussionswere held with subject matter experts and stakehold-ers. Early versions o the report were peer reviewed byexperts in the variety o areas covered.

The Councils stewardship model is based on a lib-eral (philosophical, not political) ramework steepedin the classic harm principle, which suggests that theonly time state intervention is warranted is where onesactions harm others, on one end o the continuum andclassic paternalism, which is commonly taken to mean

intererence against ones will by the state based onthe states claim that it is or the persons good, on theother. Each public health policy, even a policy o inac-tion, implies some value or ethical judgment aboutthe good o the individual and the community, andthis requires justication according to the Nueldmodel. The undamental concept behind the steward-ship model is that liberal states have a duty to lookater the important needs o people individually andcollectively.51 This duty requires the state to balancethe two extremes o the classic harm principle andclassic paternalism in order to provide conditions and

opportunities that allow people to live the healthiestpossible lie and reduce health inequities to the ullestextent possible.

Moving toward a practical application o the philo-sophical rameworks, the Council considered a broaderdebate o a number o key issues and committed toadding a social dimension to the discussion o ethicsor public health. The rst o the key issues consideredin the broader debate was the re-evaluation o individ-ual consent and its limitations in the context o publichealth. Rooted in clinical ethics, and springing rom

the Nuremberg trials o Nazi physicians, individualconsent is required or any intervention that exposes aperson to signicant risk, whether in clinical practiceor research. The question or public health is when, inthe course o practice, does a public health interven-tion reach similar risk and to what extent is individual

consent morally relevant? The authors argue that agreat deal o public health practice procedural jus-tice using conventional democratic decision-makingmight be sucient to meet the moral needs or consentwhen there are no substantive health risks. A kind ocommunity consent is acceptable when transparencyo decision-making and the most eective and leastrestrictive intervention possible is oered.

The next major area o discussion concerned healthinequalities. The Council discussed issues such aswhether the metric o success was similar health out-comes or similar opportunities or access to resources,

and within which groups or sub-groups should equality be sought.They emphasized that the only timechoice can be air is when all peoplehave equal ability and capacity tomake decisions about the choicesoered. Finally, the third key issueconsidered was the limits o inorma-tion-only approaches to sustainablebehavior change, even in the pres-ence o high individual-level motiva-tion. This might lead public health

policymakers to introduce more inva-sive policies, such as passenger restraint laws, wheninitial negative constraints are unsuccessul. Theaddition o a social dimension to the ethical consid-erations included discussions about the value o com-munity that brought the ramework closer to socialcontract theory, which values community. Commu-nity, here, was dened as the value o belonging toa society in which each persons welare, and that othe whole community, matters to everyone.52 Com-munity served as the justication to reducing inequityand limiting individual consent in avor o proceduraljustice or community consent in certain instances.

The social dimension also included a discussion aboutpaternalism, rejecting intererence against ones willor his own good, as well as the too liberal liberalpaternalism suggested by CassSustein and RichardThaler53 due to the ease with which it absolves thestate rom crucial public health responsibilities. Ulti-mately, the Council recommended a ramework orproviding public health programs with the ollowinggoals and constraints in order to meet the goal o a lib-eral stewardship model. Programs should (1) reducerisks persons impose on each other; (2) use regula-

Moving toward a practical application o thephilosophical rameworks, the Nueld Councilon Bioethics considered a broader debate o anumber o key issues and committed to addinga social dimension to the discussion o ethics orpublic health.

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tion to ensure environmental conditions that sustaingood health; (3) attend to the health o children andvulnerable persons; (4) provide programs that helpmake it easy or people to lead healthy lives; (5) ensureaccess to appropriate medical services; and (6) reducehealth inequalities. The Council also recommended

that, in terms o constraint, programs should (1) notcoerce adults into healthy behaviors or liestyles; (2)minimize interventions that are introduced withoutindividual or community consent (such as democraticdecision-making); and (3) seek to minimize any inter-ventions that intrude upon or aect important areas opersonal lie. This model, the Council believed, oersdemocratic, transparent decision-making proceduresthat ensure the appropriate balance o the interest othe individual and those o society.54

In 2010, NualaKenny et al.55 revisited their ear-lier work56 on relational ethics as an alternative phi-

losophy to ground the public health ethics ramework.Recognizing the consensus that the autonomy-ocusedapproach o clinical ethics is inadequate or publichealth, the authors suggested that a public-, social-, orcommunity-based perspective is essential. They pro-posed a theory o relational ethics, which treats per-sons as interrelated social beings, as the dierentiat-ing eature o public health ethics. Three oundationalvalues create the basis o this approach: relationalautonomy, relational social justice, and relational soli-darity. Relational autonomy, unlike individual auton-omy, recognizes that persons are linked and situated

economically, socially, and politically, intimating thatautonomy might best be served through social changeinstead o ocusing on the protection o individualliberty. Relational social justice, unlike the ocus onnon-discrimination and distributive justice (the dis-tribution o nite goods), emphasizes air access tosocial goods that include opportunities, rights, power,and sel-respect. Focusing on these aspects o justicerequires public health to look at the ethical issuesassociated with patterns o systemic injustice that pro-duce disadvantage. Finally, relational solidarity, unliketraditional ocus on altruism and oppositional catego-ries o us and them, emphasizes inclusiveness and

interconnectedness o the us all. Instead o ignoringthe dierences between people, relational solidarityrequires us to recognize them. The resulting priorityor public health is to promote the public goods orhealth, including scientiic knowledge and diseasecontrol. The authors urge the use o this relationalethical ramework as the theoretical basis or publichealth ethics because it builds upon the aims o publichealth and the core moral values o its practice.

Commonalities among Current FrameworksA common observation about the state o publichealth ethics is its lack o an agreed-upon approachor disjointed and contested theories that reuse toconverge.57 A major purpose o this review is to assesswhether the eld o public health ethics is ready to

converge on a common ramework, whether there areenough similarities across philosophical underpin-nings, oundational values in common, and similaroperating principles to converge on a single approach.As we review the columns o Table 2, it becomes evi-dent quickly that there are a wide variety o theoreticalunderpinnings proposed to serve as the basis o pub-lic health ethics. Similarly, Petrini58 outlined numer-ous ethical theories have been oered as the ultimatetheoretical basis or moral decision-making in publichealth, each oering a perspective that diers romthe others. This is problematic among philosophers,

ethicists, and others. It is air to say that Petrinis 2007statement, A syncretistic approach based on adoptingideas rom each [philosophical theory], with a view toinventing an Esperanto o ethics, is inappropriate,59resonates with theorists.

Looking at the next column o Table 2, we see thatmany o the oundational values or underlying assump-tions, belies, and perspectives across rameworks arecommon. Most speciy the need to balance respect orindividual autonomy with the elds obligation to pre-vent harm and protect health. There is a clear moverom the values o liberalism in bioethics toward the

collective o community in public health ethics. Manyo the rameworks built on the oundational valueso earlier ones, adding values to make explicit andspeciy urther the ideas o our collective obligations.Many like terms appear across the oundational val-ues column o the 13 rameworks outlined, includingautonomy, nonintererence, individual liberty, respector persons, and rights on the one hand, and obliga-tion, producing benets, preventing harms, protectingtrust, condentiality, population utility, justice, trans-parency, relationships, equality, participation, anddisparities on the other. Dierent terms in numerousrameworks speciy similar concepts. For example,

what Kass60 calls social justice is similar conceptuallyto what Childress et al.61 call distributing burdens andbenets, Upshur62 calls nondiscrimination, Thomp-son et al.63 call equity, Baum et al.64 call airness,Swain et al.65 and Jae et al.66 call justice, Petrini etal.67 call equal opportunity or health resources, theNueld Council68 calls equality between citizens,and Kenny et al.69 call relational solidarity. The con-ceptual likeness o these terms represents the sharedcommon values o respect or persons and protectiono public health across the rameworks.

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Finally, when we examine operating principlesacross the rameworks we see a wide array o tangibleexpectations and actions to guide public health prac-titioners. Operating principles included in the prac-tice-based rameworks tend to be concrete and fowdirectly rom the oundational values. Because many

o the oundational values are similar, the cascadingoperating principles are also alike across these rame-works. Operating principles included in the theory-based rameworks are less well dened. While theyoer a deeper sense o theoretical grounding, it ismore challenging to understand what a practitionershould do with the inormation in order to apply it toethical decision-making.

Currently public health ethics rameworks appearto oer no common uniying philosophical theory,some common oundational values, and a ew consis-tent operating principles. With no common approach,

how does the eld go about getting there?

Finding a Common ApproachFinding any solution, even an ethical one, requiresa well-dened statement o the problem. Starting atthe beginning, our rst question in nding a com-mon ramework is, What are we trying to do in publichealth? Stated slightly dierently, In public healthdo we have an agreed upon ultimate moral derivationrom the overall purpose o morality, which is to reducethe amount o harm in the world? This is analogousto K. DannerClousers call or a undamental uniy-

ing theoretical basis rom which all public health deci-sions could be derived70 or establishing a theoreticalunderpinning or our endeavor.

Is the public health moral imperative:To prevent or minimize harm to the health o acommunity?To promote or maximize the health o acommunity?To maximize health as a social good, understand-ing the collateral loss o unlimited (imaginary)liberty?Or something else?

Are ethical theories the only option or answering thisquestion? Given that public health is an inherentlygovernmental activity, enabled by police powers ostate law, what is the role o political philosophy as anunderpinning or dening its moral derivation? BruceJennings71 points in this direction with reerences toJohn Rawls, Joel Feinberg, and Robert Putnam; oth-ers72 have suggested political liberalism, libertarianpaternalism, and collectivism, which include bothpolitical and social philosophies. Is there a single the-

ory that summarizes the moral imperative o publichealth? I so, who decides what that is?

The next step to inding a common rameworkrevolves around clariying the oundational valuesassociated with the theoretical moral underpinning.This involves agreeing upon the important assump-

tions, belies, and values that characterize our workin the context o the theoretical underpinning. Inother words, what would it mean i we were to agreethat the ultimate moral purpose o public health wasto promote or maximize the health o a community?What values would we associate with this moral truth?Would these include a positive obligation to improvehealth? Prevent harms? Equitable distribution o bur-dens and benets? Maintaining trust? Interdepen-dence? Others? And, again, who decides?

Once the set o oundational values is established,there is a great need or tangible operating principles

to guide public health practitioners. Public healthpractitioners lack concrete agreed-upon, deensibleguidance or decision-making in complex ethical situ-ations.73 Tools to assist with recognition o ethicaldilemmas and decision support are needed or practi-tioners at all levels o public health practice.

Theoretical (even methodological) purists mightargue that these steps must proceed in order. I we areunable to complete our rst step, the identication oa uniying theory explaining our moral purpose, com-pletion o the second should not be possible. However,upon empirical observation, all o the rameworks

speciy oundational values even i these values are notassociated with overarching moral theory. As recentlyas 2008, StevenCoughlin74 recommended that urtherspecication and balance o public health ethics prin-ciples is essential or orward movement in the eld.He suggested this specication occur by (1) developingprinciples and rules, (2) reducing abstract and vaguelanguage in existing principles, and (3) providingpublic health practitioners with guides or action. Henotes that these types o mid-level principles are basedon common morality but do not stem rom an ulti-mate moral philosophy, intimating that the practice omoral decision-making in public health might be pos-

sible without our coming to agreement upon one. Theneed or ethically sound, useul decision-making toolsor public health practitioners is great, and it is up tothe great thinkers o this eld to get us there.

Next StepsThe eld o public health ethics, while relatively new,is moving orward rapidly ueled by need or ethi-cal analysis and decision-making tools at all levels opublic health as well as the growing body o work thatpushes public health ethicists to consider and recon-

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sider our theories and assumptions. A review o 13major public health ethics rameworks put orth overthe past 15 years yields a wide variety o theoreticalapproaches, some similar oundational values, and aew similar operating principles.

The question remains o whether it is possible,

necessary, or even preerable to move toward con-vergence. One might argue that i it were possibleor preerable, it would have occurred by now. Oth-ers might argue that it is not necessary or a diverseeld with a diverse set o responsibilities to operaterom a single theoretical approach. Others still mightsay that we can and should dene the duties, respon-sibilities, and margins o public health; once we dothat, our ethical underpinnings should become sel-evident.

Work remains to be done to establish a clear de-nition o the moral endeavor o public health. I one

can be agreed upon, oundational values can be out-lined rom which operating principles can cascade.The intellectual heavy liting comes at the rst step odening clearly the telos o public health, how it di-ers rom that o clinical medicine, and whether theearly conceptualization o medicine and public healthas largely distinct entities continues to hold in theera o health reorm in the United States in 2010 andbeyond. These discussions have treaded lightly andgenerally excluded public health and clinical practitio-ners. Several authors have called or a merging o pub-lic health and bioethics where clinical ethics consider

the acets o population health that could strengthenand evolve rather than replace its ramework.75 Comingto a consensus on the reach, purpose, and ends o pub-lic health will be necessary i we are to agree on whatethical underpinnings will drive us, what oundationalvalues will bring us to these underpinnings, and whatoperating principles practitioners must implementto make ethical decisions. I the eld determines it isseparate enough rom clinical medicine to warrant itsown set o ethical and philosophical underpinnings,then a decision must be made as to whether a singleapproach is warranted or we can tolerate a variety oequal but dierent perspectives.

While we wait, however, or agreement on a cleardeinition o the moral endeavor o public health,practitioners are in immediate need o concretetools or consistent and deensible ethical deci-sion-making. One attempt to bring together manyimportant contributors in the ield to summarizethe best way orward or public health ethics wasthe Nuield Council76 in the United Kingdom. Thiseort resulted in not a single theoretical approach,rather an acceptance o pieces o numerous impor-tant theories. It then put orth oundational values

and cascading operating principles rom this com-bination o ideas . While this approach has beencriticized as caeteria style ethics with weak theo-retical underpinnings,77 it might be a model to usewhen the ield is ready to consider the diicult dis-cussion o whether it is possible, or even desirable to

come to an agreement on a statement o our moralimperative and the ethical or political philosophythat best represents our complex moral duty in pub-lic health. This approach oers an opportunity orknowledgeable and invested public health proes-sionals to outline a set o guiding ethical operatingprinciples that in turn provide consistency in ethi-cal decision-making where there is currently greatneed and little concurrence. This approach alsoacknowledges a democratic and respectul plural-ism, a Rawlsian approach to accepting numerousdistinct and incompatible comprehensive doctrines

(none o which is unreasonable),78 that its well in aliberal political system that prides itsel, like publichealth, on balancing respect or persons with main-taining a society designed to advance the best in itsmembers.

Reerences1. M. Verweij and A. Dawson, The Meaning o Public in Public

Health, in A. Dawson and M. Verweij, eds., Ethics, Preven-tion, and Public Health (New York: Oxord University Press,2007).

2. Nueld Council on Bioethics, Public Health: Ethical Issues,2007, available at (last visited January 9,2012).

3. A. I. Tauber, Medicine, Public Health, and the Ethics oRationing, Perspectives in Biology and Medicine 45, no. 1(2002): 16-30.

4. See Verweij and Dawson, supra note 1.5. N. E. Kass, Public Health Ethics: From Foundations and

Frameworks to Justice and Global Public Health, Journal oLaw, Medicine & Ethics 32, no. 2 (2004): 232-242.

6. R. Bayer, C. Levine, and S. M. Wol, HIV Antibody Screening:An Ethical Framework or Evaluating Proposed Programs,JAMA 256, no. 13 (1986): 1768-1774.

7. R. R. Faden and N. E. Kass, Bioethics and Public Health inthe 1980s: Resource Allocation and AIDS, Annual Review oPublic Health 12, no. 1 (1991): 335-360.

8. L. Gostin and W. J. Curran, AIDS Screening, Condentiality,and the Duty to Warn,American Journal o Public Health 77,no. 3 (1987): 361-365.

9. D. E. Beauchamp, The Health o the Republic: Epidemics, Med-icine and Moralism as Challenges to Democracy (Philadelphia,PA: Temple University Press, 1988).

10. Institute o Medicine, The Future o Public Health (Washing-ton, D.C.: National Academy Press, 1988).

11. J. M. Last, ed., A Dictionary o Public Health (New York:Oxord University Press, 2006).

12. American Public Health Association, 10 Essential PublicHealth Services, available at (last visited January 9, 2012).

13. J. R. Williams, The Declaration o Helsinki and PublicHealth, Bulletin o the World Health Organization 86, no. 8(2008): 650-651.

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14. A. Dawson, The Future o Bioethics: Three Dogmas and aCup o Hemlock, Bioethics 24, no. 5(2010): 218-225.

15. S. D. Lane, R. A. Rubinstein, and D. Cibula, and N. Webster,Towards a Public Health Approach to Bioethics, Annals othe New York Academy o Sciences 925(2000): 25-36.

16. T. L. Beauchamp and J. F. Childress, Principles o BiomedicalEthics, 6th ed. (New York: Oxord University Press, 2009).

17. K. D. Clouser, Common Morality as an Alternative to Prin-

ciplism, Kennedy Institute o Ethics Journal 5, no. 3 (1995):219-236; C. Petrini and S. Gainotti, A Personalist Approach toPublic-Health Ethics, Bulletin o the World Health Organiza-tion 86, no. 8(2008): 624-629; C. Petrini, Ethical Issues inPublic Health and Prevention, Journal o Medicine and thePerson 5, no. 3(2007): 117-122.

18. D. J. Rothman,Strangers at the Bedside (New York, New York:Basic Books, 1991).

19. Id.20. See Beachamp and Childress, supra note 16.21. N. E. Kass, An Ethics Framework or Public Health, Ameri-

can Journal o Public Health 91, no. 11 (2001): 1776-1782.22. J. R. Childress, R. R. Faden, R. D. Gaare, L. O. Gostin, J. Kahn,

R. J. Bonnie, N. E, Kass, A. C. Mastroianni, J. D. Moreno, andP. Nieburg, Public Health Ethics: Mapping the Terrain, Jour-nal o Law, Medicine & Ethics 30, no. 2 (2002): 170-178.

23. R.E.G. Upshur, Principles or the Justiication o PublicHealth Intervention, Canadian Journal o Public Health 93,no. 2 (2002): 101-103.

24. A. K. Thompson, K. Faith, and J. L. Gibson, R. E. G. Upshur,Pandemic Infuenza Preparedness: An Ethical Framework toGuide Decision-Making,BMC Med Ethics 7 (2006): 12.

25. D. Callahan and B. Jennings, Ethics and Public Health: Forg-ing a Strong Relationship, American Journal o Public Health92, no. 2 (2002): 169-176.

26. N. Daniels, Accountability or Reasonableness, BMJ 321(2000): 1300-1301.

27. N. M. Baum, S. E. Gollust, S. D. Goold, and P. D. Jacobson,Looking Ahead: Addressing Ethical Challenges in PublicHealth Practice, Journal o Law, Medicine & Ethics 35, no. 4(2007): 657-667.

28. G. R. Swain, K. A. Burns, and P. Etkind, Preparedness: Medi-cal Ethics Versus Public Health Ethics, Journal o Public

Health Management Practice 14, no. 4(2008): 354-357.29. J. C. Thomas, Public Health Ethics, available at (last visited January 9,2012).

30. See Kass, supra note 21.31. H. W. Jae and T. Hope, Treating or the Common Good: A

Proposed Ethical Framework, Public Health Ethics 3, no. 3(2010): 193-198.

32. R. M. Granich, C. F. Gilks, C. Dye, K. M. DeCock, and B. G.Williams, Universal Voluntary HIV Testing with ImmediateAntiretroviral Therapy as a Strategy or Elimination o HIVTransmission: A Mathematical Model, The Lancet 373, no.9657(2009): 48-57.

33. See Granich, supra note 32.34. The National Commission or the Protection o Human Sub-

jects o Biomedical and Behavioral Research, The BelmontReport: Ethical Principles and Guidelines or the Protectiono Human Subjects o Biomedical and Behavioral Research(Washington, D.C.: Department o Health, Education, and

Welare, April 18, 1979).35. Council or International Organizations o Medical Sciences

(CIOMS), International Ethical Guidelines or BiomedicalResearch Involving Human Subjects, available at (last vis-ited January 9, 2012).

36. See Clouser, supra note 17.37. See Petrini and Gainotti, supra note 17.38. See Petrini, supra note 17.39. See Clouser, supra note 17.

40. D. DeGrazia, Moving Forward in Bioethical Theory: Theories,Cases, and Specied Principlism, Journal o Medicine andPhilosophy 17, no. 5(1992): 511-539.

41. J. M. Mann, Health and Human Rights, BMJ312, no. 7036(1996): 924-925.

42. M. J. Roberts and M. R. Reich, Ethical Analysis in PublicHealth, The Lancet359, no. 9311 (2002): 1055-1059.

43. B. Jennings, Public Health and Civic Republicanism: Toward

an Alternative Framework or Public Health Ethics, in A.Dawson and M. Verweij, eds., Ethics, Prevention, and PublicHealth (New York: Oxord University Press, 2007).

44. See Petrini and Gainotti, supra note 17.45. See Beauchamp and Childress, supra note 16.46. See Beauchamp and Childress, supra note 16, page 626.47. See Mann, supra note 41.48. R. B. Talisse, On Rawls: A Liberal Theory o Justice and Justi-

fcation (Belmont, CA: Wadsworth, 2001): at 14.49. See Nueld Council, supra note 2.50. See Nueld Council, supra note 2, page 153.51. See Nueld Council, supra note 2, page xvi.52. See Nueld Council, supra note 2, page 23.53. C. R. Sustein and R. H. Thaler, Libertarian Paternalism Is Not

an Oxymoron, University o Chicago Law Review 70, no. 4(2003): 1159-1202.

54. See Sustein and Thaler, supra note 53, page 26.55. N. P. Kenny, S. B. Sherwin, and F. E. Baylis, Re-visioning Pub-

lic Health Ethics: A Relational Perspective, Canadian Jour-nal o Public Health 101, no. 1(2010): 9-11.

56. F. Baylis, N. P. Kenny, and S. Sherwin, A Relational Accounto Public Health Ethics, Public Health Ethics 1, no. 3(2008):196-209.

57. A. Dawson, Commentary on The Limits o Law in the Protec-tion o Public Health and the Role o Public Health Ethics,PublicHealth 120 (2006): 77-80.

58. C. Petrini, Theoretical Models and Operational Frameworksin Public Health Ethics, International Journal o Environ-mental Research Public Health 7, no. 1(2010): 189-202.

59. See Petrini, supra note 17, at 121.60. See Kass, supra note 21.61. See Childress et al., supra note 22.62. See Upshur, supra note 23.

63. See Thompson et al., supra note 24.64. See Baum et al., supra note 27.65. See Swain et al., supra note 28.66. See Jae and Hope, supra note 31.67. See Petrini and Gainotti, supra note 17.68. See Nueld Council, supra note 2.69. See Kenny et al., supra note 50.70. See Clouser, supra note 17.71. See Jennings, supra note 43.72. See Nueld Council, supra note 2.73. R. G. Bernheim, Public Health Ethics: The Voices o Practi-

tioners, Journal o Law, Medicine & Ethics 31, no. 4, Supp.(2003): 104-109; N. M. Baum, S. E. Gollust, S. D. Goold, P. D.Jacobson, Ethical Issues in Public Health Practice in Michi-gan, American Journal o Public Health 99, no. 2 (2009):369-374.

74. S. S. Coughlin, How Many Principles or Public Health Eth-ics? Open Public Health Journal1(2008): 8-16.

75. J. R. Williams, The Declaration o Helsinki and PublicHealth, Bulletin o the World Health Organization 86, no. 8(2008): 650-652; A. Dawson, The Future o Bioethics: ThreeDogmas and a Cup o Hemlock, Bioethics 24, no. 5 (2010):218-225; S. D. Lane, R. A. Rubinstein, D. Cibula, and N. Web-ster, Towards a Public Health Approach to Bioethics,Annalso the New York Academy o Sciences 925 (2000): 25-36.

76. See Nueld Council, supra note 2.77. See Petrini, Petrini and Gainotti, supra note 17.78. J. Rawls, Justice as Fairness: A Restatement(Cambridge, MA:

Belknap Press, 2001).

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