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Principles for the Justification of
Public Health Intervention
R.E.G. Upshur, MA, MD, MSc, FRCPC
ABSTRACT
Objectives: The objective of this paper is to discuss principles relevant to ethical
deliberation in public health.
Methods: Conceptual analysis and literature review.
Results: Four principles are identified: The Harm Principle, The Principle of Least
Restrictive Means, The Reciprocity Principle, and The Transparency Principle. Two
examples of how the principles are applied in practice are provided.
Interpretation: The paper illustrates how clinical ethics is not an appropriate model for
public health ethics and argues that the type of reasoning involved in public health ethics
may be at potential variance from that of empirical science. Further research and debate
on the appropriate ethics for public health are required.
The framework of principalism has
proven to be robust and useful as a
means of assisting practicing clini-
cians to organize their thinking about ethical
issues in clinical medicine. Surveys done by
Coughlin and others have pointed out the
relative lack of systematic instruction in
ethics in both public health and epidemiolo-
gy.1,2 Thus, there is a need for ethics instruc-
tion in both epidemiology and in schools of
public health. Conceptual research on frame-
works for ethical reasoning, recognizing the
essential differences between public health
practice and clinical medicine, is necessary.
The focus of public health is directed to pop-
ulations, communities and the broader social
and environmental influences of health. As
well, there is a greater focus on prevention
than on treatment or cure. It is not clear that
simply importing conceptual models from
clinical ethics will suffice for public health as
the philosophy that underlies public health
differs from that of clinical medicine.3
Public health practice differs substantially
from clinical practice. The context, mandate
and range of activities carried out by public
health practitioners encompass a wide set of
considerations. Most public health depart-
ments are part of state, provincial or federal
governments. The overarching concern for
the individual patient found in clinical
ethics is not neatly analogous to a concern
for the health of a population. As well, there
is no clear analogy to the fiduciary role
played by physicians. Simply put, popula-
tions are constituted by diverse communities
of heterogeneous beliefs and practices. These
may at times come into conflict. Individual
versus community rights and conflicts with-
in and between communities are the more
likely locus of ethical reflection in public
health practice. Hence, public health ethics
must recognize and be able to reason
through issues relating to social, political and
cultural contexts; the existence of competing
values and perspectives and perhaps, incom-
mensurable world views. Given these con-
siderations, it is clear that the straight-
forward application of the principles of auto-
nomy, beneficence, non-malfeasance and jus-
tice in public health practice is problematic.
The principalist framework has come
under heavy criticism in clinical ethics.4
Modern bioethics, which concerns itself
with ethical issues both within and beyond
clinical medicine, consists of a wide range of
theories including virtue ethics, feminist
ethics, and utilitarianism (to name a few), all
The translation of the Abstract appears at the end of the article.
Department of Family and Community Medicine, Public Health Sciences and The Joint Centre for
Bioethics, University of Toronto, Primary Care Research Unit, Sunnybrook and Women’s College
Health Sciences Centre, Toronto, ON
Correspondence: Dr. R.E.G. Upshur, Primary Care Research Unit Room E349B, Department of Family
and Community Medicine, Sunnybrook and Women’s College Health Science Centre, 2075 Bayview
Avenue, Toronto, ON M4N 3M5, Tel: 416-480-4753, Fax: 416-480-4536, E-mail:
rupshur@idirect.com
Acknowledgements: Dr. Upshur is supported by a Canadian Institutes of Health Research New
Investigator Award and a Research Scholarship from the Department of Family and Community
Medicine, University of Toronto. The author thanks Shari Gruman for her assistance in preparing the
manuscript.
MARCH – APRIL 2002 CANADIAN JOURNAL OF PUBLIC HEALTH 101
of which may have some relevance to public
health ethics. The strength of a principle-
based approach is its heuristic nature and
applicability to practice. Gostin has noted
that one problem in defining the sphere of
ethics in public health is the broad ambit of
public health activities. He makes the dis-
tinction between the ethics of public health
(concerned with the ethical dimensions of
professionalism and moral trust that society
invests in professionals to act for the com-
mon good), ethics in public health ( which
incorporate the ethical dimensions of public
health enterprise; the moral standing of pop-
ulation’s health; trade-offs between collective
goods and individual interests and social jus-
tice considerations) and ethics for public
health (the value of healthy communities;
interests of populations, particularly the
powerless and oppressed; and pragmatic
methods).5A set of principles for public
health practitioners to use in the practice of
public health may thus be useful for system-
atic reflection on ethical issues. In what fol-
lows, a set of principles for the analysis of
ethical issues in public health practice is
articulated and analyzed. It is not intended
that these principles be regarded as defini-
tive, but rather heuristic. The principles have
been distilled from a reading of the nascent
literature in public health ethics. They seek
to bring clarity to some of the ethical aspects
of public health decision making in practice.
The focus of these principles relates to the
question of when public health action is jus-
tified. Hence, the locus of application of
these principles is restricted to a specific, but
significant domain. The principles articulat-
ed will not, for example, cover screening and
prevention programs, health promotion pro-
grams or public health research.
Principles
Harm Principle
The harm principle as set out by John Stuart
Mill is perhaps the foundational principle for
public health ethics in a democratic society.
It sets out the initial justification for a gov-
ernment, or government agency, to take
action to restrict the liberty of an individual
or group. The harm principle is succinctly
stated by Mill: The only purpose for which
power can be rightfully exercised over any mem-
ber of a civilized community, against his will, is
to prevent harm to others. His own good, either
physical or moral, is not a sufficient warrant.6
It is important to note that the harm prin-
ciple does not specify what action to take,
but merely states that action is justifiable in
this context.
Least Restrictive or Coercive Means
This principle recognizes that a variety of
means exist to achieve public health ends,
but that the full force of state authority
and power should be reserved for excep-
tional circumstances and that more coer-
cive methods should be employed only
when less coercive methods have failed.
Education, facilitation, and discussion
should precede interdiction, regulation or
incarceration. It should be pointed out that
the principle does legitimate coercive
means where justified and where less
restrictive means have failed to achieve
appropriate ends. This principle has been
enshrined in the Siracusa principles, a set
of internationally agreed upon legal princi-
ples that establish the justified conditions
for the restriction of civil liberty.7 The
Siracusa principles hold that restrictions of
liberty must be legal, legitimate and neces-
sary and use the least restrictive means that
are reasonably available. Furthermore,
there should be no discrimination in their
application.
Reciprocity Principle
Once public health action is warranted,
though, there is an obligation on a social
entity such as a public health department to
assist the individual (or community) in the
discharge of their ethical duties. Complying
with public health requests may impose bur-
dens on individuals. These may involve sac-
rifice of income or time and in general, these
should be compensated. The reciprocity
principle holds that society must be prepared
to facilitate individuals and communities in
their efforts to discharge their duties. It is
discussed more thoroughly by Harris and
Holm.8
Transparency Principle
This principle refers to the manner and con-
text in which decisions are made. All legiti-
mate stakeholders should be involved in the
decision-making process, have equal input
into deliberations, and the manner in which
decision-making is made should be as clear
and accountable as possible. As much as pos-
sible, the decision-making process should be
free of political interference and coercion or
the domination by specific interests. The
process should strive toward what Habermas
has termed an “ideal speech situation”.9
Example 1
Case 1. Smear Positive TB: A 35-year-
old homeless male is found to be smear
positive for MTB. The man is frequently
non-compliant with medication and
uses shelters on nights when it is cold.
In this case there is a potential for harm to
others as someone smear positive for tuber-
culosis is capable of transmitting the disease.
Sleeping in a crowded shelter is an opportu-
nity for such transmission to occur.
Therefore the harm principle is met and
action of some form is justifiable. In terms of
limiting the harms, the least restrictive
means principle would hold that public
health officials start with attempts to educate
and move progressively up through Directly
Observed Therapy (DOTS), supportive
housing, voluntary admission, to involuntary
detention.10-12 The reciprocity principle
holds that public health officials have an
obligation to not just provide the man with
options, but facilitate the discharge of his
obligations. Interventions such as DOTS
and supportive housing are founded, in part,
on the recognition of the need for such
social reciprocity. Finally, guiding the entire
process should be a clear and transparent
communication including the provision of
legal counsel if necessary.
Example 2
Case 2. Concerns over a toxic exposure:
The health department is called to investi-
gate community concerns regarding
chemicals leeching into the water table.
An epidemiological investigation fails to
show any linkage of the exposure to
health outcomes, but the sample sizes are
small and the confidence intervals around
the estimates wide. Nonetheless the com-
munity persists in its belief of adverse
health effects.
In this case it is questionable whether the
harm principle is met. In essence, there is
uncertainty and no persuasive evidence of
health impact from an epidemiologic point
of view. However, psychosocial impacts
from environmental exposures may be con-
siderable,13 and using a holistic definition of
health, harm may indeed have occurred.
Whether the harm principle is satisfied in
this case is, therefore, arguable. Given that
PRINCIPLES FOR PUBLIC HEALTH INTERVENTION
102 REVUE CANADIENNE DE SANTÉ PUBLIQUE VOLUME 93,NO. 2
Mill’s principle does not explicitly state how
harms are to be understood, it does not pro-
vide clear guidance unless one wishes to
invoke the use of principle on behalf of the
community and order an immediate clean-
up.
In this example, legally sanctioned inter-
vention on the part of the health department
may not be warranted. It is likely that both
parties to the dispute will interpret the
harms differently. Despite this, there is still a
need for reciprocity and transparency. If
there is no clear warrant for action by public
health, there is still an obligation on the part
of the department to play a role in facilitat-
ing communication and mutual understand-
ing so long as the issues remain focused on
health.
Ethical reasoning in Public Health
How are the above principles brought into
practice? There has been an increased recog-
nition of the need to assess reasoning as it
applies to health care practice.14 Ethics is
essentially a reflective task that requires par-
ticipants to be explicit about what they
believe, why, what they value and on what
grounds. This process should be conducted
in the context of rational discourse. The
introduction of value issues into “objective-
scientific” reflection has often been regarded
as a potential bias. Yet this rests largely on
lack of clarity on the role and meaning of
values in science.15
Walton argues that public health delibera-
tions rest on a different logic than scientific
reasoning. The standard of evidence or bur-
den of proof required for public health
action may be at variance with that of tradi-
tional conceptions of scientific reasoning.
Walton refers to this as tutiorism.16 Scientific
reasoning relies on confirmation of results
and is oriented to avoiding Type I errors.
Public health, on the other hand, often takes
action to prevent harm even when the evi-
dence may be uncertain. The words of A.B.
Hill are appropriate here. Hill is aware that
evidence is usually incomplete and hence
there is a need for differential standards for
action. After noting that on very slight evi-
dence we may wish to reduce hazards to
pregnant women and on fair evidence to
make interventions in workplaces, it may
require very strong evidence to intervene in
the lifestyles of people. He writes: “In asking
for very strong evidence I would repeat,
emphatically, that this does not imply cross-
ing every “t” and swords with every critic
before we act.”17
The idea of a differential evidence stan-
dard for public health action is a fertile one
that requires further development. In public
health practice, the evidence may not be
clear or the evidence may be characterized by
underdetermination.18,19 This commonly
occurs in public health. We shall never have
randomized control trial evidence of many
environmental exposures such as chemicals,
and many proposed interventions are subject
to long lag times before effects are noted.
Underdetermination occurs when the data
can be interpreted in many ways that are
plausible but conflicting. This can occur for
statistical reasons such as model selection, or
because of unexpressed or unacknowledged
value or epistemic commitments. The prob-
lem of underdetermination is not limited to
observational studies.20 It may be a general-
ized feature of knowledge acquisition.21
CONCLUSION
Ethics in public health requires systematic
attention. In this paper, I have argued for
the differences between public health and
clinical care, defined and illustrated a set of
principles for public health practitioners to
use in the analysis of using public health
powers. The utility of these principles in
practice also requires evaluation. There is
often a long lag time between the conceptual
analysis of ethical issues and their empirical
evaluation. This paper intends to stimulate
debate, research and scholarship on an
important dimension of public health prac-
tice.
REFERENCES
1. Coughlin SS, Etheredge GD. On the need for
ethics curricula in epidemiology. Epidemiology
1995;6(5):566-67.
2. Coughlin SS, Katz WH, Mattison DR. Ethics
instruction at schools of public health in the
United States. Association of Schools of Public
Health Education Committee. Am J Public Health
1999;89(5):768-70.
3. Weed DL. Towards a philosophy of public health.
J Epidemiol Community Health 1999;53(2):99-104.
4. Beauchamp TL. Principalism and its alleged com-
petitors. Kennedy Inst Ethics J 1995;5(3):181-98.
5. Gostin LO. Public health, ethics, and human
rights: A tribute to the late Jonathan Mann.
J Law Med Ethics 2001;29(2):121-30.
6. Mill J. On liberty. In: Wishy B (Ed.), Prefaces to
Liberty: Selected Writings. Lanham, MD: University
Press America, 1959.
7. Coker R. Detention and mandatory treatment for
tuberculosis patients in Russia. Lancet
2001;358(9279):349-50.
8. Harris J, Holm S. Is there a moral obligation not to
infect others? BMJ 1995;311(7014):1215-17.
9. Habermas J. The Theory of Communicative Action.
Vol 1. Reason and the Rationalization of Society.
McCarthy, T. (trans). Boston: Beacon Press; 1984.
10. Annas GJ. Control of tuberculosis—the law and
the public’s health. N Engl J Med
1993;328(8):585-88.
11. Bayer R, Dupuis L. Tuberculosis, public health,
and civil liberties. Annu Rev Public Health
1995;16:307-26.
12. Singleton L, Turner M, Haskal R, et al. Long-term
hospitalization for tuberculosis control. Experience
with a medical-psychosocial inpatient unit. JAMA
1997;278(10):838-42.
13. Elliott SJ, Taylor SM, Walter S, et al. Modelling
psychosocial effects of exposure to solid waste facili-
ties. Soc Sci Med 1993;37(6):791-804.
14. Horton R. The grammar of interpretive medicine.
CMAJ 1998;159(3):245-49.
15. Longino H. Science as Social Knowledge. Values and
Objectivity in Scientific Inquiry. Princeton, NJ:
Princeton University Press, 1990.
16. Walton D. The New Dialectic: Conversational
Contexts of Argument. Toronto: University of
Toronto Press, 1998.
17. Hill A. The environment and disease: Association
or causation? Proc Roy Assoc Med 1965:295-300.
18. Weed DL. Underdetermination and incommensu-
rability in contemporary epidemiology. Kennedy
Inst Ethics J 1997;7(2):107-27.
19. Oreskes N, Shrader-Frechette K, Belitz N.
Verification, validation and confirmation of
numerical models in the earth sciences. Science
1994;263:641-46.
20. Jadad AR, Cook DJ, Browman GP. A guide to
interpreting discordant systematic reviews. CMAJ
1997;156(10):1411-16.
21. Barrow J. The Limits of Science and the Science of
Limits. Oxford: Oxford University Press, 1998.
Received: December 4, 2000
Accepted: November 15, 2001
PRINCIPLES FOR PUBLIC HEALTH INTERVENTION
RÉSUMÉ
Objectifs : Étudier les principes d’un débat éthique en santé publique.
Méthode : Analyse notionnelle et enquête bibliographique.
Résultats : Nous avons cerné quatre principes (réduction des méfaits, choix des moyens les moins
restrictifs, réciprocité et transparence) et fourni deux exemples de leur application dans la pratique.
Interprétation : Le modèle de déontologie clinique ne convient pas à la santé publique, car le type
de raisonnement employé pour les questions éthiques en santé publique peut être différent de celui
des sciences empiriques. Il faudrait pousser la recherche et le débat pour définir un modèle éthique
qui convienne à la santé publique.
MARCH – APRIL 2002 CANADIAN JOURNAL OF PUBLIC HEALTH 103