A Journey in Public Health Ethics
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A Journey in Public Health Ethics
ABSTRACT

While medical ethics has a long history, and research ethics guidance emerged more formally in the 1960s and 1970s, frameworks for public health ethics began to appear in the 1990s. The author's thinking about public health ethics evolved from consideration of some of the ethics and policy questions surfacing regularly in the HIV/AIDS epidemic. This essay discusses some of the shared commitments of public health and ethics, as well as how one might apply an ethics lens to public health programs, both generally and in the contexts of public health preparedness and obesity prevention.

Like others with many interests, I found picking a major in college a bit stressful. It was a relief to discover that Stanford, where I attended, had recently developed an interdisciplinary major called Human Biology, allowing me to study many things at once. "HumBio" had four main requirements: a year of coursework in biology, integrated with a year of social science core courses; a self-designed "area of concentration"; an internship; and a public policy course on either health or the environment. In the years since I graduated, options for areas of concentration have become more structured, but we had significant flexibility. My self-designed concentration was "A Feminist Approach to Public Health," [End Page 103] something I look back on with astonishment, since I recall feeling like I was simply assembling a group of classes I wanted to take—feminist theory and human physiology and medical ethics, among others—but of course in retrospect it is fundamental to what I care about years later.

Yet it was the last two program requirements that shaped my next steps more centrally. For the internship, I volunteered at two women's health clinics: the local Planned Parenthood and the Haight-Ashbury Free Clinics' women's clinic in San Francisco, at the latter of which I continued to volunteer weekly for years beyond both the internship's requirements and graduation. These provided enough experience that I could get a job at another women's health clinic after graduation, doing whatever counseling and management someone with no actual skills might be allowed to do.

The last requirement for the major was a class in public policy. The Program in Human Biology had been started by Donald Kennedy, a Stanford professor who, when I enrolled, had just finished his term as commissioner of the Food and Drug Administration (FDA), and by the time I graduated, had become Stan-ford's eighth president. Kennedy's commitments to public policy ran deep, and he thought we needed policy training side by side with whatever academic and interdisciplinary science training Stanford provided us. Taking the health policy class, dramatic as it may sound, changed my life. The class was organized as a series of guest lectures from luminaries of the time in public health and health policy—Victor Fuchs, Alain Enthoven, Molly Coye, Len Syme, Hal Sox, Phil Lee, and Ted Marmor—names that, at the time, meant nothing to me, though as students we were impressed that we often read books or articles written by the people giving the lecture. In retrospect, this class might have been called an introduction to public health. I had my first lecture in epidemiology, my first lecture in social determinants of health, my first lecture in health economics, and my first lecture in decision theory. We learned about prevention, and a theme throughout was the significant role of policy in public health and American health care. I was completely energized writing my final exam, and I asked the professor to consider me, if I did well enough, to be a teaching assistant the following year. I ended up TAing that class for two years, an all-consuming, totally fun, and formative experience, as the eight TAs each led two breakout sessions per week and wrote and graded class assignments and exams. This only deepened my interest in health, prevention, and policy.

After graduation, I was hired as a counselor and then front office supervisor at another northern California women's health clinic. I loved everything about the job: our mission, the work I was...


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