Some thoughts on public health ethics

Yesterday I attended a symposium on public health ethics held at my university. It was an interesting experience, as like most sociologists I am not very familiar with the literature on public health ethics, although I have drawn upon some of  it from time to time. However I am very interested in the moral, political — and yes, sometimes the ethical dimensions — of public health, and a great deal of my research has focused on these issues (for example, Lupton, 1995, 2012; Petersen and Lupton, 1997).

When listening to the presentations defining public health ethics, and later following up some of the literature mentioned in the symposium, it was apparent to me that academics writing in the public health ethics field also do not appear to read sociological analyses of public health (or if they do, they not cite them very often). So neither field is currently engaging with the other to any great extent. Why this lack of interaction, given that there are clear overlaps between the critical sociology of public health and public health ethics? The approach known as ‘critical public health ethics’ is especially close to the concerns of the critical sociology of public health as it tends to focus to a greater extent on the politics and power relations inherent in public health (Callaghan and Jennings, 2002). Both critical public health ethics and the critical sociology of public health are interested in how public health strategies and models affect individuals and populations; both want to engage in a critique of the taken-for-granted assumptions that pervade public health; both pay attention to the potential for injustice, excessive paternalism and constraint of freedom within public health approaches; both address the issue of why certain issues are identified as ‘public health problems’ and why others are ignored; and both draw attention to the focus on individuals’ health-related behaviours in public health and the need to highlight the broader social, cultural and political causes of ill-health and disease.

Probably the main reason for the lack of recognition of the literature on both sides is the different histories of public health ethics and the critical sociology of public health. Public health ethics is a very new field that grew from bioethics, a type of applied ethics. Public health ethics and bioethics are based very strongly on the underpinnings of traditional moral and political philosophy (Carter et al., 2012). As a result a lot of writing in public health ethics is preoccupied with distinguishing between the various philosophical approaches that can be used to evaluate public health strategies:  for example, what insights a utilitarian, libertarian, human rights or distributive justice perspective may offer. Public health ethicists weigh up these various perspectives when evaluating the claims of public health and make decisions on what is the most ethical action based on their reasoning. They tend to publish their work in mainstream journals of public health or in specialist medical or public health ethics journals.

The critical sociology of public health has less of an applied focus than public health ethics, tending to focus more on the social structural features underpinning public health approaches and engaging in a more overtly political critique. Sociologists writing in this area usually position themselves outside of public health, while in contrast public health ethicists often position themselves inside public health as part of their role of attempting to advise on the best course of action. While sociologists may often refer to ‘ethics’, they are not generally concerned with comparing different ethical perspectives and evaluating them. They tend to have a far more relativist approach to ethics, and indeed may engage in an analysis of medical or public health ethical discourse itself as a socially constructed phenomenon (see, for example, Jallinoja, 2002).

Further, while the critical sociology of public health is also informed by philosophy, sociologists have taken up different theorists to conduct their analyses, drawn largely from what is often termed ‘grand theory’. In particular sociologists have employed the political economy approach influenced by Marxism and more recently the writings of Foucault on biopolitics, biopower, governmentality and the care of the self. The critical sociology of public health also has somewhat of a longer history than critical public health ethics. It has been in existence for some decades, as found particularly in articles published in the journal Critical Public Health, established in 1979 under the original title of Radical Community Medicine, but also in several other sociology journals. Sociologists of public health and public health ethicists therefore tend to publish in very different journals and as a result do not tend to routinely see each other’s work.

Despite their major differences (and perhaps because of these differences) it would be interesting to see how each field could gain from a greater engagement with and acknowledgement of each other’s work. It is intriguing to think about what synergies may be generated by such an engagement. I hope that this post represents one small step in this direction.

References

Callaghan, D. and Jennings, B. (2002) Ethics and public health: forging a strong relationship. American Journal of Public Health, 92, 169—76.

Carter, S., Kerridge, I., Sainsbury, P. and Letts, J. (2012) Public health ethics: informing better public health practice. NSW Public Health Bulletin, 23(5-6), 101—6.

Jallinoja, P. (2002) Ethics of clinical genetics: the spirit of the profession and trials of suitability from 1970s to 2000. Critical Public Health, 12(2), 103—118.

Lupton, D. (1995) The Imperative of Health: Public Health and the Regulated Body. London: Sage.

Lupton, D. (2012) Fat. London: Routledge.

Petersen, A. and Lupton. D. (1997) The New Public Health: Health and Self in the Age of Risk. London: Sage.

8 thoughts on “Some thoughts on public health ethics

  1. I could not agree more about the natural connection between the inter-related fields of public health ethics and critical public health. They both take to task the assumptions made about the benefit of public health and call into question the approaches that professionals take to improve the health of populations. I have found that the ‘age’ of the two areas has something to do with the disconnect. I recently presented at a bioethics conference at my university on the topic of how social media venues challenge the established public health structures for communication by allowing the public to construct new knowledges about health and resistance of established messages.

    The audience was mostly physicians and attorneys, with a few philosophers thrown in. Though they could relate to these practices as ethical challenges in the practice of public health, they did not quite know what to do with it. What I was presenting was basic critical sociology, but it was new to them. However the interest to bridge the divide was there, and I think that more dialogue and cross-publishing will be welcome and helpful.

  2. Hi Deborah,

    Fascinating post! At risk of further shameless self-promotion, I think the differences you describe between PHE and critical public health track a debate within public health itself, viz., whether a broad or a narrow model is the optimal model for guiding public health practice, policy, and priorities (“Narrow” is not at all meant as a pejorative in the sense of ‘narrow-minded’ or any such thing; it just refers to the scope and the intended objectives).

    That is, there’s an exciting debate within public health regarding whether public health ought to be characterized by a narrow focus on the big 6 services or rather by a broad focus that pays attention to macrosocial variables and the political economy of health (SDOH, etc.). I think what you observe within PHE really tracks that larger debate. In the U.S. at least, dominant strains of PHE track the dominant model of public health, which is still IMO firmly positioned within the narrow model that has characterized the profession since the early decades of the 20th c. (I do not mean to be American-centric by stating that I most familiar with this debate in its American context, although I think many of the issues involved are relevant in almost any Western setting given how histories of public health in the West have proceeded).

    A practice of PHE that hewed closer to the broad model of public health would IMO track much more closely some of the elements of critical public health you note here. For example, and again to shamelessly self-promote, I have found it absolutely critical to engage Link & Phelan’s fundamental cause theory specifically in PHE, as well as their and other sociologists’ work on stigma. Attention to the structural determinants of health, to political economies, these and other Marxist or at least Marxist-flavored approaches are central to the kind of PHE work I aspire to do. This is out there, I think, but the narrow model of public health still dominates, with the majority of PHE work itself tracking that dominance. Again — this is not intended as any kind of jab at such work, much of which I find rigorous and instructive. It just has a different focus than a PHE that engages a broad model of public health, and might explain what you observed at the PHE conference.

    • Thanks for your comments, Daniel. You have made some interesting observations about the different ways in which public health approaches its task. I agree that public health ethics, given its generally applied focus and its position as an advisor to and within public health, clearly has to deal with this tension between wanting to focus on serving as such an advisor and actually making more directly critical comments that postulate a challenge to the entire definition of what public health should define itself and what it should seek to do.

  3. Deborah, thanks for your post, which reflects exactly the division that I and colleagues recently writing in Critical Public Health identified in our discussion of public health attitudes to smoking (http://www.tandfonline.com/doi/abs/10.1080/09581596.2012.706260). From the perspective of medical humanities, we felt able to suggest that both public health and sociology held only partial views of the human condition and that the engagement between these two views, together with medical humanities, would help critique to become co-construction – to the benefit of those who are the target of health interventions.

    • Thanks, Jane. I actually read your article recently and really enjoyed the perspectives you and your colleagues offered. I’ve been writing about the concepts of risk and pleasure, risk and resistance and the use of commodities such as cigarettes as part of the construction of selfhood for a while, and think that these issues are generally under-explored in public health and health promotion. And yes, I agree wholeheartedly that the medical humanities have much to offer both the sociology of medicine and public health and public health ethics. It would fantastic to get scholars from all three together in one room some day … (and also media and cultural studies and medical anthropology, for that matter).

  4. Thanks Deborah for you very interesting blog post! I think that there may actually be more overlap in work on social justice and public health, and in general, in critical writing on public health (without specific reference to public health ethics). However, I agree that there needs to be much more engagement of those working on the critical sociology of public health, public health ethics and also the critical anthropology of health.

    I just posted your post to the Facebook Public Health Ethics page — hopefully that will generate more dialogue.

    The Ethics Forum, which is a special interest group of APHA, is a good place for more dialogue.
    The Annual Meeting of the SPIG will be held on Tuesday, October 30, 2012: 6:30 PM – 8:00 PM at the APHA meetings in San Francisco. All are welcome (not just SPIG members).

  5. Pingback: Dispositivos de Saúde Pública — Quais as abordagens críticas?" | Controle Social de Sarandi

  6. Pingback: Dispositivos de Saúde Pública Quais as abordagens críticas?" | Portal do Controle Social

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