ETHICS-BASED PUBLIC HEALTH POLICY?

Brownson et al. provide an effective and exhaustive framework for the implementation and assessment of health policies.1 They address the scientific, economic, social, and political forces that inform health policies. Surprisingly, however, ethics is completely absent from the overview. The awareness that public health is an inescapably moral enterprise2 is neither new nor widely contested3; in fact, the utmost relevance of ethics in public health is unanimously recognized.4 The authors must certainly agree with this perspective, but they evidently deemed it inopportune to include the ethical dimension in their analysis. In my opinion, this omission jeopardizes the completeness of the authors' model for both theoretical and practical reasons. The theoretical reason is evident: if public health is “the science and art of preventing disease, prolonging life and promoting health through organised efforts of society,”5 and if ethics is theoretical reflection on the nature of the good and on what we ought to do,6 then public health ethics—determining what we ought to due in pursuit of the good of public health—is unavoidable. The practical reasons are perhaps less evident. Ethics appears more concerned with theoretical reflections, whereas health policies direct concrete courses of action; yet, ethics loses its purpose if it does not guide specific, practical policies. Ethical analysis has three main aspects: descriptive (what is right and good?), theoretical (what are the justifications for what is right and good?) and normative (how can we act in accordance with what is right and good?).7 Once descriptive and theoretical aspects are addressed, the normative aspect takes into account the three elements at the basis of every ethical judgment: means, circumstances, and ends.8 Their entwinement with the corresponding three key domains of evidence-based policy (processes, contents, and outcomes, respectively) is clear. Thus, an ethically sound health policy is likely to be a practical, effective health policy.9 Recognizing ethics as an opportunity—and not an obstacle—is therefore fundamental for public policy, because the implementation of effective “policy analysis lies squarely (if uncomfortably) between science and ethics.”10 Although ethical decision making is not a matter of applying principles and automatically generating an answer, acknowledging its practical role will help close the gap between the two fields. As Brownson et al. point out, health policy should consider both qualitative and quantitative evidence. I would add that it should also consider ethical evidence. Sound health policies will stem from the synthesis of all three.