Exploring the Prominence of Ethical Principles and Moral Norms in the Areas of Clinical Practice and Public Health
Citation: Akrami F, et al. Exploring the Prominence of Ethical Principles and Moral Norms in the Areas of Clinical Practice and Public Health. Ann Med Health Sci Res. 2018; 8: 11-15
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Background and Aim: Health policies and public health practices have always been confronting with dilemmas about proper extent to achieve its goal and conflicts with individual freedoms in its activities. This study aimed to explore the prominence of ethical principles and moral norms in the areas of clinical and public health practice. Methods: In this study, literature was purposefully searched in English in the original databases, including ISI, Scopus, Embase and PubMed in the period 1980-2016, and then, related articles were analyzed. Results: Contrary to public health activities focused on maintaining and improving the health of populations, because of the patient-centered approach of clinical practice, its activities are focused mainly on the treatment or rehabilitation. So that, the principle of respect for patient autonomy, plays a central role in clinical practice. But, in the field of public health the principle of justice has central role in order to reducing inequalities in health outcomes. Moreover, in addition to the distribution of opportunities, benefits and resources, strengthening the autonomy of individuals for healthy choices rather than restriction of autonomy is necessary. Conclusion: Public health authorities committed to incorporate ethics in their practice should create an organizational context with an ethical ground. It is strongly recommended to create a public health ethics framework for decision-making in public health policies and interventions.
Ethics; Moral norms; Clinical practice; Public health; Health policy; Justice
New approaches to health and social responsibility should be developed to ensure that scientific and technological advancements contribute to the justice and human utility. Current health status in different parts of the world is a great concern. Universal Declaration on Bioethics and Human Rights considered health as a social and human good, since better access and improved levels of high quality health care are recommended as much as access to safe drinking water. [1,2]
Daniels states that health is a special moral importance, since it enables people to pursue their opportunities in life and take advantage of health care beyond clinical context and hospital, including public health policy.  Health refers to something more than biological malfunction or functional disorders such as movement, vision or hearing. Even if having pain is not considered an obstacle to appropriate biological function, it is contrary to health; therefore, the sexual malfunction  and infertility are likewise. Thus, health is a reflection of a moral concern and all of these are critical in the stability of human existence throughout their life. 
More than 100 years ago, public health was founded as an organized system aimed at improving population health rather than individual health.  Unlike medical practice, which is related primarily to patients, public health practice focuses on the population health. The primary goals of public health are disease prevention and health promotion rather than the treatment of patients. [6,7] According to the current classic definition of the Institute of Medicine (IOM), “the public health is what we, as a community, do it collectively to assure the conditions, in which people can be healthy”.  This definition refers to a collective effort”, but at the same time refers to the goal of ensuring the conditions, in which people can be healthy. The public health is not only the traditional practice of government to protect the public against imminent threats, but on a more fundamental level, is a cooperative behavior and trustworthy relationships in communities and equally a broad agenda to address complex social, behavioral and environmental conditions affecting health. Bioethics helps health professionals and policy-makers detect moral dilemmas in health care and biomedical researches and offers ethical principles and rules to guide them. Considering the public health focus on the population, this area has always been confronting with dilemmas about the proper extent to achieve its goal and conflicts with individual freedoms in its activities. Hence, there is a need to a systematic ethical framework which guides professionals in decision-making, planning, and evaluation of the public health interventions.  But what is in question, is whether the dominant liberal approach to medical ethics is appropriate in the public health practice, too. It has been widely acknowledged that answer to ethical questions in the public health requires a different approach away from the traditional medical ethics.  Since, the present study aimed to explore the prominence of ethical principles and moral norms in the areas of clinical practice and public health, meanwhile addresses their differences.
In this study, the literature was searched in English using the following keywords in the major databases, including ISI, Scopus, PubMed, and Embase in the period 1980-2016, and then, the related articles were analyzed.
(“Public health/ethics” [MeSH Terms]) OR “public policy/ ethics” [MeSH Terms]) OR “public health administration/ ethics” [MeSH Terms]) NOT “research” [MeSH Terms]) AND (“ethics/standards” [MeSH Terms]) OR “normative ethics” [MeSH Terms]).
Applied ethics seeks to interpret the general norms to respond to specific issues and name this field as applied ethics is because of the fact that it refers to the use of general norms in thinking about the issues, problems and policies in different professions and institutions as well as governments. Common morality embraces moral norms that are considered as fundamental norms for the biomedical ethics. Most moral theories somehow incorporated these principles and codes of traditional medical ethics have pointed some of these principles. The above principles that include the principle of respect for autonomy, beneficence, nonmaleficence and justice; act as an analytical framework and are considered as the starting point for biomedical ethics. These principles should act as general guidelines for establishing more specific rules. Principles and rules are both general requirements and norms and the main difference is that moral rules are more specialized in terms of content and are more limited in terms of scope, compared with the ethical principles. Principles of beneficence and non-maleficence have a central role in the history of medical ethics. In contrast, respect for autonomy and justice are neglected in the traditional medical ethics and has become more prominent recently. In fact, professional ethics in medicine is to give applicability to general ethical manners in the field of the medical activities. For example, rules such as informed consent and confidentiality in medicine are rooted in more general ethical requirements such as respect for patient’s autonomy and to protect them against harm. In other words, the above rules in medical ethics are the result of application of more general principles that may not be applied outside of the medical and research scope. 
Public policy ethics provides a deliberative framework and a process for public justification, so that the supply and allocation of scarce resources for specific interventions are political questions that must be solved in policy area. This process involves extensive interaction between community stakeholders and the public in the development of political consensus and support for public health activities. Although public health values and code of ethics can be part of the public deliberation on the policy, justifications in any particular case, are based on an analysis of benefits and burdens of certain options, and interests and moral claims of all affected parties. 
Public health ethics is a relatively new field of applied ethics and is related with ethical implications of a wide range of activities aimed at maintaining and improving population health. Public health ethics is a field that covers both real and ethical considerations in the health policy and health science.  The public health ethics investigates evolution and effect of different perceptions of the concept of “people”, as a political group with defined commitments, obligations and legal relations as well as diverse cultural and moral understanding. 
Article 25 of the Universal Declaration of Human Rights explicitly recognizes the right to health. Article 12 of the International Covenant on Civil and Political Rights implies the need to recognize “the right of everyone to the highest attainable standard of physical and mental health” by the government. So, protecting the public health is one of the most important goals of the state. In most countries the surveillance system is organized at the national level, which means it is the state responsibility. However, these systems suffer from multiple pathologies that affect their performance. [13,14] The states have positive commitments to improve public health, and of course, reducing evident and avoidable social inequalities. Therefore, a public health ethics framework, in addition to providing a fair protection and considering the negative rights of citizens for non-interference, must emphasize on positive rights. Public health ethics should also address the functions of the public health in the field of social justice. 
The American Public Health Association considers 10 basic functions necessary for the performance of public health,  which is the reason why various ethical frameworks have been proposed in Table 1.
|1.||Monitor health status to identify community health problems.|
|2.||Diagnose and investigate health problems and health hazards in the community.|
|3.||Inform, educate, and empower people about health issues.|
|4.||Mobilize community 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.||Link people 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.|
Table 1: American Public Health Association; “10 Essential Public Health Services”_2010.
The performance of public health shows that public health is a morally significant action with ethical foundations. It still seems that some public health interventions are considered a threat to moral norms, such as autonomy, privacy and confidentiality.
Public health officials are encountered countless decisions in maintaining and protecting people’s health, prevention of disease, disability and death, and population health promotion. Questions and ethical issues are raised in codification of both laws and policies, and decisions on unspecified cases.  For example, which law or policy related to violations on privacy and confidentiality can, as best as possible, protect the public health and the rights of persons with communicable diseases? And if this is allowed by law or policy, but not necessary, how breach of confidentiality as disclosing information to third parties such as sexual partners under certain circumstances is morally justifiable to public health officials? What other factors, including moral factors are related to this decision and public health authorities on what moral grounds can justify their decisions?
Ethical considerations in public health
Public health ethics code was created in 2002 under the votes of public health leadership society made up of representatives of several organizations involved in the public health. The goal was “to highlight the ethical principles that follow from the distinctive characteristics of public health.” [Table 2]. The presence of several ethical principles underlying the code is a fundamental belief in the interdependence of human beings as the “essence of the society.” This belief is expressed not only in public health efforts “to ensure the health of all communities”, but also to recognize the inseparable link between individual health and collective life. The authors of this code consider it important “for public health and other American institutions with a public health mission”. Also, they stressed that it would be considered useful and relevant for the institutions and individuals whose work is effective on the public health, even those without a “clear mission for public health”.  Although ethical principles in the code provide a useful guide for practical decision in the public health, what the code states, does not provide sufficient public justification for public health policies and measures. Such a justification originates from the request for a range of common moral values and norms, embedded in the social institutions, including law as well as the ethical principles in the code.
|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 for, or work for the empowerment of, disenfranchised community members, ensuring that the basic resources and conditions necessary for health are accessible to all people in the community.|
|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.|
Table 2: Principles of the ethical practice of public health (Public Health Leadership Society).
Childress et al., conceptualized general moral considerations represent ethics in the public health practice [Table 3]. These considerations, which are often called moral norms along with values, principles, rules, and likewise may be interpreted differently in different ethical frameworks. However, Childress and Bernheim claim that the moral contents of public health are largely, if not completely, caught by those. [12,17]
|2.||Avoiding, preventing, and removing harms|
|3.||Producing the maximal balance of benefits over harms and other costs (often called utility)|
|4.||Distributing benefits and burdens fairly (distributive justice) and ensuring public participation, including the participation of affected parties (procedural justice)|
|5.||Respecting autonomous choices and actions, including liberty of action|
|6.||Protecting privacy and confidentiality|
|7.||Keeping promises and commitments|
|8.||Disclosing information as well as speaking honestly and truthfully (often grouped under transparency)|
|9.||Building and maintaining trust|
Table 3: Moral considerations in public health.
Public health interventions and goals are related to ethical principles, particularly beneficence and non-maleficence (utility) and justice. The public health is an instrumental and intrinsic public good in itself, because it enables the society to act. As a result, public health is followed by the beneficence principle. In discussing beneficence, administration of justice for a fair distribution of benefit in society requires attention to the special risk of individuals to suffer from disease and harm. [12,17]
The principle of justice is the fundamental moral justification for social institution of public health . People require justice standards when they are in a position to do the act of beneficence or imposing costs. The term, distributive justice, implies a fair, equitable distribution specified with justified criteria of social cooperation principles. 
The differences in prominence of the moral norms in the areas of clinical practice and public health
First, public health not only focuses on the individuals’ health but also tries to improve the population health. Second, public health focuses on preventing and reducing harm, disease and death not treatment of the disease, and third, public health requires a collective effort requires government action and its goals cannot be achieved through individual effort. [7,11] Moreover, the public health is inherently consequentialist.  Although in both performance areas, beneficence is the ultimate goal, public health focus on the prevention and health promotion, has always confronted this area with moral conflicts with the activities of individual freedoms and autonomy constraints. [5,17] But because of patient-centered approach in the clinical practice, activities are mainly focused on treatment or rehabilitation and the relationship between doctor and patient, so that the principle of respect for autonomy and respecting its rules, such as informed consent, privacy and confidentiality become more prominent. However, due to differences in the approaches of these two areas, in public health, the principle of justice, including distributive justice for a fair distribution of benefits and burdens of the program, equal access, reducing inequalities in health outcomes, and procedural justice in the form of the participation of all parties affecting the decisionmaking process is central. [5,17,19,20] Hence, public health’s measures include data registration, collection, surveillance and researches conduct on population health.  Differences in clinical and public health practices and applications of moral norms in these areas have summarized in Table 4.
|Clinical practice||Public health practice|
|Medical interventions to cure or treat existing illness||Programs and interventions to promote community health and human wellbeing|
|provided by public and private practitioners||Provided by governments|
|A limited number of similarly clinically trained professions deliver care(e.g., physicians and nurses)||An increasingly diverse group of practitioners round out the effective team, including public health officials, epidemiologists, statisticians, physicians, economists, behavioral scientists, and policymakers|
|Usually single effort||collective effort, usually via government to bring about participation of the public|
|Focused on patient autonomy||Public benefits prevails individual autonomy|
|Focus on justice is usually faint and usually indicates on a fair moral character||The focus on justice emphasizes social justice, or rights to health care, and disparities in access and outcomes.|
|Clinical practice and research||Public health functions, surveillance, vital statistics, disease and injury registry and reporting, and collection of data, investigate outbreaks, conduct contact tracing, and provide health education and other preventive interventions, and conduct research related to public health.|
Table 4: The differences in prominence of the moral norms in the areas of clinical practice and public health.
Public health, as a social endeavor, includes numerous forms of collective actions and increasingly consists of individual and organizational overlapping networks, including governmental and private agencies, profit and non-profit parties, specialists from many disciplines, and citizens, all of who work to improve people’s health and living conditions of community over time.
Building relationship between public health officials and the public and gaining their trust is not merely a mean, but rather a part of the foundation of public health work. Specially, public health interventions at the local community level, such as interventions that focus on behavioral, social and economic risk factors are multidimensional, time-consuming and dependent on the context. Public health campaigns for reducing tobacco use in youth are examples of complex, multifaceted programs that need the alliance and partnership, as much as the numerous social institutions such as public education system, to effectively change behaviors and social norms related to smoking among adolescents. In this atmosphere of public health, ethical analysis involves something beyond professional, organizational and civil duties. Beyond protecting public health and social and governmental job, performance of some norms, may actually be means or even a precondition for achieving public health.  The World Health Organization’s (WHO) definition of health as a “state of physical, mental and social well-being” requires a broad approach to public health, although the well-being is reduced to health in this definition.  For example, strong evidence indicates on the significant role of social injustice in the health conditions and human rights violations as “adverse effects on bio-psycho-social well-being”. Therefore, reducing public health ethics only to resolving moral conflicts and responding to moral dilemmas is a mistake. 
Some studies have investigated principles of medical ethics and public health in national regulations and archives, but did not differentiate between them.  Nonetheless, the use of political power by the government, especially in paternalistic or mandatory policies, raises important ethical questions in a democratic society and the need to ethically justify issues, which are expected to be rationally accepted by the public. As noted, the focus of public health on the public interests has always confronted this area with individual autonomy. Least infringement of autonomy in public health policies and programs, as a moral norm, is originated from the principle of respect for the autonomy. Unlike clinical ethics and its emphasis on respect for patient’s autonomy, social justice is the fundamental moral justification for public health social institution.  The term “social justice” is a common term in the field of public health.  The recent theories of justice, including the theory of capabilities and well-being theory focus on precondition abilities for well-being or the wellbeing itself. In other words, freedom of action, capabilities, enabling educations, and strengthening of the autonomy and their resources are considered as well-being equipment. From this perspective, the job of justice is to ensure an adequate level of six fundamental dimensions of well-being, including health, reasoning, self-determination, attachment, personal security and respect for all. [4,18] In describing these theories, justice is something more than addressing the distributive principles. In addition, understanding justice is beyond their distributive share for each person and equally relates to the nature of the relationship among the individuals. For example, concerns about the social stigma, disrespect, lack of organizations and social functions for adequate protection of existing capacities for self-determination are among issues raised in the area of justice, both for individuals and for groups.  These theories of justice state that it is not sufficient to distribute opportunities, benefits and resources and have freedom of choice for healthy behaviors, but those believe in nurturing of reasoning abilities and strengthening the autonomy of individuals for healthy choices. [4,18] Buchanan argues that the goal of improving populations’ health is achievable by expanding the autonomy through promoting a concept of justice, which is defined as the development of human flourishing.  In our study, titled politico- moral foundations of country’s health system, we have identified egalitarianism as the dominant theory without explicit attention to reinforcement of individuals’ autonomy as a dimension of human well-being to achieve social justice. 
Contrary to public health activities focused on classic goal of maintaining and improving the health of populations, because of the patient-centered approach of clinical practice, its activities are focused mainly on treatment or rehabilitation. Thus, the principle of respect for patient autonomy, play a central role in clinical practice. But, in the field of public health the principle of justice has central role in reducing inequalities in health outcomes. Also, in public health researches, including surveillance systems, due to addressing the population health, public interests and justice dominate the autonomy. Therefore, health policy-makers to achieve public health goal should leave decision-making without considering other public policies that effect on health and well-being.
Finally, public health officials committed to incorporate ethics in their practice should create an organizational context with ethical ground. This can be done by tying performance standards to moral principles and encouraging employees to integrate ethics in their work through the development of measurable goals and outcomes based on the values and principles of public health. Beyond this, it is recommended to create a public health ethics framework for decision-making and planning in public health policies and interventions, strongly.
This study is a part of PhD Thesis in the field of Bioethics. The authors acknowledge scholars who participate in preparation of this work.
Conflict of Interest
All authors disclose that there was no conflict of interest.
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