Public health ethics come into play when weighing the trade-offs in decision-making, said keynote speaker Lisa Lee at the APHA 2022 Closing General Session, “Building Public Health Capacity Through an Ethical Lens to Address Social Challenges.”

Lee, an epidemiologist, bioethicist and ethics educator, is associate vice president for research and innovation at Virginia Tech, and co-leader of the APHA task force that created the Association’s 2019 Public Health Code of Ethics. The code can be used to sharpen ethical considerations when conducting assessments on population health and social and racial justice; investigating environmental health hazards; engaging with a community; developing policies and plans; and applying evidence-based research, Lee said at the session. 

Lisa Lee

“Public health ethics is a verb, something we do, a decision-making framework when values conflict,” she said.

But values can be subjective and lead to harm. Lee gave the example of the late John Charles Cutler, who, as acting chief of the venereal disease program with the U.S. Public Health Service, led a series of experiments in the 20th century in which patients were infected with syphilis without consent. The purpose, according to Cutler, was to study the patients to advance science and improve population health. 

“He defended his work as necessary for science,” Lee said. “He valued scientific discovery beyond anything else. He followed his own moral compass. And he was wrong.” 

While this is a rather straightforward case showing an unacceptable health harm to people infected, other public health cases are more ethically complex. The COVID-19 pandemic illustrated this as public health professionals had to decide when to man-date — and then lift — business and school closures and other public gathering restrictions.

“Closing a business makes sense from a health perspective but is damaging to a business economically,” Lee said. Balancing those competing interests can be hard, as shown during the pandemic.

During the session’s panel discussion, Rueben Warren, professor of bioethics and director of the National Center for Bioethics in Research and Health Care at Tuskegee University, summed up how one’s personal ethics is an unreliable guide, as shown with Cutler.

Rueben Warren with David Holtgrave in the background. “The intention to do good is very different from doing good,” he said.

That is where the APHA code comes in. The code is designed to get stakeholders talking about ethical trade-offs, but also practical issues on conducting a fair and moral community intervention that respects and listens to community members. It offers six core values and eight considerations for decision-making, which helps objectify the decision-making process on ethical issues. The document is not meant to impact disciplinary proceedings or sanction professional misconduct.

Ethics are the “moral governance of public health, a constellation of values that motivate our work,” Lee said.

David Holtgrave, of the U.S Office of National Drug Control Policy, talked about the similarities between APHA’s code of ethics and his agency’s ethical framework set forth in the National Drug Control Strategy

Public health workers can defer to either guide when considering the trade-off between harm reduction strategies for patients versus continued substance dependence, among other considerations. 

“Both are evidence-based (and) highlight health disparities, social determinants of health, recovery health (and) transparency,” Holtgrave said.

In public health, ethics cannot be ignored, Lee said. Practitioners need to adhere to them to be effective in the field.

“It is about trust, but to get trust we have to be trustworthy,” Lee said. That means acting in an “ethical way with our community’s best interest at heart.”

Photos from top: Lisa Lee; Rueben Warren with David Holtgrave in the background. Photos by EZ Event Photography.