A Role for Moral Vision in Public Health

Bioethics and public health are largely estranged. Questions of moral and political philosophy are relevant to the means and ends of public health, but often go unasked. Population-level concerns are of mounting importance for bioethics. Greater engagement between bioethics and public health would yield benefits for both fields.

Public health rests on assumptions about what it means to live a good life. The concepts of health and well-being are a matter of values as well as of fact; they are informed by considerations about what makes life worth living. Similarly, the degree to which the state should intrude on personal liberty to improve public health hinges on the scope of individual autonomy. Critical examination of these claims would help public health practitioners balance competing values and assumptions. Such engagement should consider not only the effect of public health on the moral dimensions of individual health, but also the complex web of relationships that are social determinants of health. At the same time, greater engagement with public health would help bioethics grow as a field; bioethics would develop new competencies and modes of thinking, which would in turn shed light on other population-level issues.

Greater engagement between bioethicists and public health researchers and practitioners could lead to more open discussions of the role that values can and should play in shaping public health policy and informing public health practice. This would be very helpful for the field of public health. On a practical level, values are relevant to public health because individuals’ values affect health-related behaviors and thus are themselves issues in public health interventions. Individuals’ values may prove to be an impediment for health interventions, but also may be a tool for change.

A critical examination of public health’s norms would compel the field to reflect on the way that values inform its activities and to confront the mixed legacy of its early history. The norms operative in public health are often obscure because the underlying questions go unexamined. Ignoring the vital role that values play in shaping current public health policy invites the same hubristic tendencies that once coopted public health and used it for forced sterilization, eugenics, and other forms of “social hygiene.” If public health is to be intellectually honest, it must evaluate norms critically and examine how, historically, it has interacted with and been shaped by social values and political beliefs.

The most fundamental and compelling reason for public health to develop its moral vision through engagement with bioethics is that the methods and ultimate goals of public health are, at least in part, contingent on the question of what it means to lead a good life. While public health interventions were once accomplished through improvements to infrastructure—for example, through better sanitation and clean water—today public health goals often require changing individual behavior, often through state action. Such interventions raise substantive questions about the extent to which government, in a democracy, should intrude on individual bodies to improve the health of the body politic. While others have discussed similar concerns under the rubric of health and human rights or “public health ethics,” these areas of study have only been ancillary outgrowths of bioethics. I think a more integral incorporation of these concerns is needed. These questions are not merely academic or philosophical—ask anyone who has been questioned, isolated, quarantined, or inoculated by the state against his or her will. Questions about what the state may do and how far it may go to achieve public health outcomes are also pressing to legislators, regulators, and lawyers. Finally, they are of deep political relevance to all who are committed to the values of an open and democratic society.

While fundamental values underlie public health practice, they also inform the goals of public health policy. What it means for an individual to be healthy and well is as much a question of the nature of human flourishing as of physiological functioning. When should we privilege mortality over morbidity? Should we measure a quality-adjusted life year, and if so, how? What about subsidizing “wellness” interventions with...