APHA Public Health Code of Ethics

American Public Health Association

2019

TABLE OF CONTENTS

1. Introduction
2. Public Health Core Values and Related Obligations
3. Guidance for Ethical Analysis
4. Ethical Action Guidance for Policy and Practice in Functional Domains of Public Health

SECTION 1. INTRODUCTION

The Public Health Code of Ethics is a set of professional standards and expectations intended for public health practitioners1 throughout the field. In 2002, a code entitled Principles of the Ethical Practice of Public Health was developed by a team of public health practitioners engaged in a project with the Public Health Leadership Society. The American Public Health Association adopted the principles, and they were published in the American Journal of Public Health2 . At that time, it was already recognized that the field of public health was experiencing dynamic growth and that the code would best serve the field if it were occasionally reexamined and possibly revised. Now, as the field of public health enters the era of Public Health 3.0, in which public health practitioners and programs prioritize social determinants for health and interact with a growing diversity of partners, it is important to reexamine and reemphasize public health’s commitments to ethical practice and public service. Public health practitioners work in a variety of settings, including but not limited to local, state, and national governmental public health departments; domestic and international nongovernmental organizations (NGOs); and academia. Practitioners within each setting come from a variety of disciplines and represent numerous scientific and technical areas of study. The values and standards of public health apply to practitioners in these and other public health settings and disciplines. In a practical and multidisciplinary activity as complex as public health, acting ethically and fulfilling ethical obligations requires careful refection and intentional decision making. Public health is an evidence-informed practice. Public health actions are based on scientific observation and inference, lived experience, and what is valued by public health practitioners. Public health decisions affect the health and well-being of diverse individuals, groups, and communities. This 2019 version of the Public Health Code of Ethics contains ethical standards and obligations for both public health practitioners and institutions, and it is intended to guide individual and collective decision making, especially in ethically challenging situations. Section 2 outlines the “what” of public health ethics; it lists and defines the shared foundational values of public health. These values form the high-level moral justification for public health work. Section 3 provides guidance for the “how” of public health ethics; it provides a set of considerations for use in a deliberative decision-making process that allows public health practitioners to ensure that authority and power in public health are exercised in fair and productive ways. Section 4 provides ethical guidance for actions and implementation strategies in 12 domains of public health practice, as identified by the Public Health Accreditation Board (PHAB)3 . These domains do not exhaust the full range of the field of public health, but they do provide a well-recognized and useful map within which to organize the important action guides offered in this code. Those practicing public health who do not locate their own activities on this map may nonetheless be able to develop similar action guides that are germane to their own field of operation.

Addressing complex ethics questions requires public health personnel to have a set of skills that include the ability to:

• Identify the ethical dimensions of public health work,
• Articulate conflicting values and ethical dilemmas when they arise,
• Deliberate on options and courses of action using inclusive methods that engage individuals and groups affected by public health work, and
• Implement and evaluate solutions to keep the process open for revision, especially in situations where information is limited or developing quickly.

How can social justice and the ideals and standards of normative ethics be integrated within the structure of professional activity? Historically, part of the answer to this question has been provided by formal, written codes of professional ethics. Yet, assessments differ concerning the purposes served by professional codes of ethics. Some critics regard professions as nothing more than ways of making a living, or pathways to prestige and power. Accordingly, these critics tend to regard ethics codes as self-serving statements that protect the power and status of the profession and its members more than they protect the public interest.

However, even though codes have been used in professionally self-serving ways, they have also provided standards that critics and reformers have used to render professionals more accountable and trustworthy. It is important not to lose sight of the impartial ethical validity of the norms that codes can contain.

This code is premised on the belief that professions are not merely special interest groups within society but are charged and entrusted—more stringently than other occupations—with service to society. As such, professions must be dedicated and accountable to the people they serve. A code is not the only lens that society uses to evaluate the performance of its professions, but it is a visible statement of the collective conscience of a profession, and it is one benchmark against which specific professional practices can be measured.

If, for the entire profession, a code is like a promise to society, for an individual professional a code is part of a special commitment and a second identity. As human beings in families and societies, all people have ethical standards, rights, obligations, and a personal moral conscience. When people become professionals, they take on a second set of special responsibilities and obligations concerning how and for what ends their professional knowledge and authority should be used. At times, the special obligations of one’s professional identity can come into conflict with one’s personal interests and even obligations. Fulfilling the special ethical obligations of a professional is not easy. When health care professionals report for duty during a public health emergency, for example, they must leave their home and family, perhaps during a frightening and difficult time. Public health and safety professionals are expected to take risks and to put themselves in harm’s way as a professional ethical obligation. Also, they are expected to put the public interest and the public trust ahead of their personal interests and to never misuse their office or authority for personal gain. Codes are documents in which such special professional obligations are pledged and explained.

When reflecting on ethics, many first think of regulation, supervision, and formal enforcement. This code is not a disciplinary or regulatory document; its importance derives from values and standards widely shared in the public health profession and from the force of reasoned argument. It is meant to address the field of public health, and it is not intended to be used to discipline and sanction professional misconduct. It offers a discussion of ethics that is sensitive to the varied nature of public health work and the contexts in which it takes place. It provides an ethical framework to guide both individuals and organizations engaged in the pursuit of the health of the public. Regulation, supervision, and formal enforcement play their part in ensuring that professional conduct meets high ethical standards, but these matters should be addressed by duly authorized agencies and organizations.

Identifying and cultivating ethical best practices is a reflective and dynamic endeavor. This code does not rest exclusively on any single theoretical approach to ethics such as rights-based approaches or utilitarian orientations. Instead, the theoretical stances informing this code are pluralistic: it describes foundational values that inform and animate public health across various ethical schools of thought, shows how these multiple values complement and conflict with one another, and examines the practical implications these values hold for policy and the beneficial use of public health expertise and authority today.

Public health is a multidisciplinary profession including numerous specialized bodies of knowledge and practical experience useful in service to society. As previously stated, the Public Health Code of Ethics takes its guiding orientation from the focal point of that service. While many discussions take the goal of this service to be individual and population “health,” this code uses the notion of “flourishing” or well-being, which has a broader, more inclusive connotation. With the appropriate support, many live flourishing lives with impairments or illness. As used here, flourishing does not focus so much on biological function as on the social conditions of capability and opportunity upon which health itself and many other goods depend.

Flourishing refers to what individuals and communities experience when institutional and cultural structures create the opportunity for people to realize a wide range of potential capabilities inherent in all human beings. Flourishing occurs when capabilities for agency, creativity, intelligence, understanding, emotional engagement, and other positive human potentialities take shape in the form of lives well lived. As such, we take a life course perspective that examines public health issues from maternal and child health into old age while recognizing specific vulnerabilities at the extremes of age. The term human flourishing also underscores the relational interdependence among human beings, which is expressed in virtually all social and cultural activity and fts well with the contemporary understanding of the social determinants of health. The preconditions of everyone’s health are communal and systemic, and the field of public health must address them as such. Human flourishing is thus consonant with a social-relational, rather than an exclusively individualistic, interpretation of key values such as human rights, liberty, equality, and social and environmental justice that play a vital role in contemporary public health.

The opposite of human flourishing is not only disease or ill health but also domination, inequity, discrimination, exploitation, exclusion, suffering, and despair: in a word, the stultification and denial of optimal human self-realization and thriving human communities.

We return once more to the fundamental question of how the ideals and standards of ethics can be integrated within the structure of professional activity in public health. If a rigorous and comprehensive code of ethics helps achieve this goal, the promulgation of written codes of ethics alone is not enough to ensure ethical professionalism in practice. More direct systemic, institutional, cultural, and psychological influences shape the ethical conduct of public health practitioners. These factors must be addressed head on and met with strategic efforts at organizational change and professional capacity building in public health. Updating and adopting the Public Health Code of Ethics is only the first step.

Therefore, it is important for professions to follow up and supplement the adoption of a code with other ongoing activities and with additional tools and resources for the training and development of sound ethical decision making in the field. Debate and discussion of the provisions of an ethics code can prompt and set in motion a healthy process of institutional self-refection and sensitization. Empirical and philosophical research in public health ethics has increased significantly in recent years and has become an important area of scholarship. It will continue to examine specific areas of public health policy and practice, and ways should be found to bring the findings of such research to the attention of public health practitioners.

Periodic workshops and community meetings—among public professionals on the staff of agencies or NGOs and between public health practitioners and the communities they serve—can provide an opportunity to analyze what should be done in real-world case studies and scenarios.

Discussion forums such as these, together with other uses of social media, webinars, and training programs, can play a meaningful part in promoting and sustaining a humane and respectful ethos of moral respect and care in public health. Ongoing professional development and ethics competency building in public health can help the field learn from past crises, take steps to avoid repeating past mistakes, and address the structural and cultural factors that result in the conduct of the field falling short of its own ideals and those of the broader society.

SECTION 2. PUBLIC HEALTH CORE VALUES AND RELATED OBLIGATIONS

The following core ethical values are equally important and are not presented in rank order. These values are multifaceted conceptually and can be realized in practice in different ways. They do not have simple definitions. They require ongoing and explicit refection and reaffirmation.

A. Professionalism and Trust. The effectiveness of public health policies, practices, and actions depends upon public trust gained through decisions based on the highest ethical, scientific, and professional standards. Public health gains public trust in part because its practices are informed by evidence. When the needed evidence is lacking, public health seeks it, and when the evidence reveals faulty or inadequate practices, public health seeks to improve those practices. At times public health practitioners must respond to a situation in the absence of complete scientific information, which highlights the importance of having an ethical framework to drive decision making. Public health practitioners and organizations promote competence, honesty, and accuracy and ensure that their work is not unduly influenced by secondary interests. Public health decision makers need to be transparent and honest about disclosing conflicting interests and influences.

B. Health and Safety. Health and safety are essential conditions for human flourishing. Public health practitioners and organizations have an ethical responsibility to prevent, minimize, and mitigate health harms and to promote and protect public safety, health, and well-being.

C. Health Justice and Equity. Human flourishing requires the resources and social conditions necessary to secure equal opportunities for the realization of health and other capabilities by individuals and communities. Public health practitioners and organizations have an ethical obligation to use their knowledge, skills, experience, and influence to promote equitable distribution of burdens, benefits, and opportunities for health, regardless of an individual’s or a group’s relative position in social hierarchies. Health justice and equity also extend to ensuring that public health activities do not exacerbate health inequities. In addition, health justice does not pertain only to the distribution of scarce resources in transactions among individuals; it also involves remediation of structural and institutional forms of domination that arise from inequalities related to voice, power, and wealth. It is difficult for public health to promote health justice at the transactional level if it does not take steps to promote it at the structural and institutional levels as well.

D. Interdependence and Solidarity. The health of every individual is linked to the health of every other individual within the human community, to other living creatures, and to the integrity and functioning of environmental ecosystems. Public health practitioners and organizations have an ethical obligation to foster positive—and mitigate negative—relationships among individuals, societies, and environments in ways that protect and promote the flourishing of humans, communities, nonhuman animals, and the ecologies in which they live. Attention to potential intergenerational conflicts over resources can sometimes be essential.

E. Human Rights and Civil Liberties. While coercive legal measures limiting behavior can be ethically justified in certain circumstances, overall the effective and ethical practice of public health depends upon social and cultural conditions of respect for personal autonomy, self-determination, privacy, and the absence of domination in its many interpersonal and institutional forms. Contemporary public health respects and helps sustain those social and cultural conditions.

F. Inclusivity and Engagement. Preventing adverse health outcomes and protecting and promoting the flourishing of individuals, societies, and ecosystems require informed public decision-making processes that engage affected individuals and communities. Public health practitioners and organizations have an ethical responsibility to be transparent, to be accountable to the public at large, and to include and engage diverse publics, communities, or stakeholders in their decision making.

SECTION 3. GUIDANCE FOR ETHICAL ANALYSIS

Ethical analysis can help public health practitioners and organizations assess what they should do and why. Grounding action in the core values presented above provides public health with a publicly defensible approach. In addition, sometimes values and ethical obligations conflict, resulting in the need to find common ground and seek integrity-sustaining compromise. Resolving ethical tensions does not mean finding the right answer; rather, it means searching for a morally appropriate way forward, all things considered.

As an integral part of the exercise of professional deliberation and judgment concerning proposed public health actions, skill in ethical analysis and reasoning is an important competency for public health practitioners and decision makers. Ethical analysis of proposed or contemplated public health actions involves four important components:

• Determination of the public health goals of the proposed action
• Identification of the ethically relevant facts and uncertainties
• Analysis of the meaning and implications of the action for the health and rights of affected individuals and communities
• Analysis of how the proposed action fits with core public health values

Such an analysis involves assessing the best available factual evidence, understanding the lived experience of affected stakeholders, and thinking explicitly through how the moral justification for the proposed public health action or program can best be publicly justified and explained. Finally, ethical analysis also includes steps to set up procedural arrangements that respect the interests and values of affected stakeholders and provides for direct or indirect participation of those stakeholders in the decision-making process.

Ethical goals and values are often at stake in a public health action or decision, and it is not always clear how they should be ranked or how conflicts between different goals and values should be resolved. Through serious discussion of the following considerations in a deliberative decision-making process, public health practitioners can strive to ensure that authority and power in public health will not be exercised in ways that are arbitrary, discriminatory, or otherwise abusive of the public trust. Below are eight considerations that should arise in virtually any setting where public health interventions and policies are planned and significant decisions concerning such interventions and policies are made. If these issues are not considered, whatever the ultimate decision, it would be difficult to say that the decision had been given sufficient ethical scrutiny.

• Permissibility: “Would the action being considered be ethically wrong even if it were to have a good outcome?” Ethics seeks to define and distinguish conduct that is morally permitted from conduct that is morally prohibited. An action is often judged to be morally acceptable based on two factors: the extrinsic consequences of the action and the inherent nature or meaning of the action. Sometimes motivation and intention are factored in as well. Evaluating the consequences of a proposed action or decision alone is always ethically pertinent, but it is not ordinarily ethically sufficient. To identify actions that are ethically suspect, public health practitioners must consider the social and cultural context of the proposed action. A given action might have permissible consequences—such as gaining new knowledge that can be used beneficially in the future— but nonetheless be a type of action that is prohibited because of social, cultural, and historical experience and consensus. One clear example of an impermissible action is torture; another is discrimination based on race, gender, ethnicity, or functional impairment. Such actions violate values that today are recognized as central to the mission of public health. Public health decision making and practice will normally function within the zone of ethically permissible actions, but even within that zone difficult and important value trade-offs must be made. For example, limiting the spread of sexually transmitted diseases requires a trade-off between privacy rights of individuals and use of methods, such as contact tracing, that have been effective in limiting the spread of disease in a population. Finally, a discussion of the criterion of permissibility in moral reasoning would be incomplete without brief mention of a complex topic: the relationship between ethics and the law. Ethical public health practice must be set within the parameters of the law at any given time and within established procedures for changing the law over time. An ethical professional should strive to work within the law to serve the needs, rights, and well-being of individuals and society at large. In addition, individual professionals and organizations can ethically strive to change the law through the democratic and judicial process. (It should be noted that some public health practitioners might be restricted in their exercise of democratic citizenship by conditions of their employment in the government or nonprofit sector.)

• Respect: “Would the proposed action be demeaning or disrespectful to individuals and communities even if it benefited their health?” Respect supports human dignity within transactions, exchanges, and relationships. These considerations remain relevant even when—indeed, especially when—there is a significant disparity in need or resources among the parties involved. Respect also reminds us of the important values of justice and equity, as well as interdependence and solidarity. It is particularly important to safeguard the dignity of those who, by virtue of young age or cognitive disability, may not be able to fully participate in democratic deliberation or give consent or even assent.

• Reciprocity: “Have we done what is reasonable to offset the potential harms and losses that the proposed action imposes on individuals and communities?” The ethical ideal of reciprocity attests to the notion that social life should reflect mutual exchanges and cooperation rather than unilateral imposition. Reciprocity obligates us to relieve, as much as is reasonable, the burdens of adhering to public health policy. When a public authority requires individuals and communities to contribute to or participate in an important communal undertaking, it is incumbent on that authority to provide the means necessary to ensure that such contributions are not unduly or unreasonably burdensome. For example, if public health practitioners are sent to the location of a public health emergency, they must be provided with proper training and appropriate equipment. Similarly, if public health subjects individuals to compulsory quarantine or social distancing measures, it is the ethical responsibility of public health and other officials and agencies to provide appropriate medical assistance, housing conditions, nutrition, access to outside communication, and other human rights protections throughout the course of their isolation.

• Effectiveness: “Is it reasonable to expect, based on best available evidence and past experience, that the proposed action would achieve its stated health goals?” Once the planned goals of a proposed public health action are determined to be morally permissible, it is then necessary to assess how well those permissible goals will be met. Given the best information presently available, a proposed public health action or decision should be able to achieve its intended public health goal. Action for its own sake without a reasonable likelihood of effective success is not ethically justified. For example, in an epidemic situation, especially one involving an unfamiliar pathogen or a grave infectious disease, measures involving quarantine or restriction on travel or assembly might be considered for political reasons, even when the evidence of their effectiveness in containing the epidemic is weak. Since substantial human, environmental, and economic costs—intended or unintended, current or long term—are associated with such measures, lack of evidence for their effectiveness would provide one ethical argument against their use.

• Responsible Use of Scarce Resources: “Would the proposed action demonstrate good stewardship and deserve the trust that the public has invested in public health practitioners?” Virtually every public health action, particularly those for which difficult ethical judgments must be made, involves the use of scarce resources such as human skill, talent, and time; medical equipment and supplies or other infrastructure; natural resources; and funds that could be directed to other activities. Even if permissible and effective on its own terms, ethical decision making requires consideration of whether a given action merits expenditure of resources in relation to other needs or health goals that require attention now or in the foreseeable future. For example, a possible future health emergency can be less devastating if large quantities of medical supplies or equipment—such as antivirals or ventilators—are stockpiled in reserve. But those stockpiled resources could go unused for a long period and even expire, while other ongoing public health programs and services are underfunded.

• Proportionality: “Would the proposed action demonstrate that public health practitioners are using their power and authority judiciously and with humility?” Virtually every public health action has both benefits and costs, particularly those for which difficult ethical judgments must be made. Proportionality involves assessments of the relative effects, positive and negative, of an action or a decision. A proportionate action would be one in which the means used to attain a public health goal are reasonable in light of the benefits they bring and the costs they impose, provided that those benefits and costs are distributed equitably and in a fair and nondiscriminatory way. Conversely, a disproportionate action would be one that involves a very small chance of significant benefit to a few and the cost of widespread deprivation or harm to many. For example, it has been argued that public health and safety goals can at times justifiably override other values, such as personal liberty, but that public health actions should nonetheless adopt the least restrictive alternative that will meet the public health goal. It should also be noted that the notion of proportionality can be thought of temporally as well as spatially: the prospect of disproportionate risk of harm can apply to both current and future generations. These judgments are perhaps more complex in the case of impact on future persons, but that is no reason to ignore their ethical significance.

• Accountability and Transparency: “Would the proposed action withstand close ethical scrutiny and be justified by valid reasons that the general public will understand?” Public health practice relies on the support and voluntary cooperation of individuals and communities, both of which require trust. Trust is built on ongoing transparency and accountability. This can involve explaining actions and motives even when no critical questions are being asked. By giving an account of the reasoning and evidence behind a program, public health practitioners demonstrate respect for affected communities and stakeholders. This also helps members of the public understand the difficulty and seriousness of purpose involved in public health decision making, even if they disagree with the specific decision or outcome in question. Real-time transparency, especially in crisis or emergency situations, might not always be feasible or desirable; protecting individual privacy and avoiding public panic might be overriding considerations. But retrospective transparency of evidence and ethical reasoning is almost always a good ethical practice. It is the hallmark of learning organizations and reflective professional practice.

• Public Participation: “In deciding on a proposed action, have all potentially affected stakeholders had a meaningful opportunity to participate. If some are to be deliberately excluded from decision making, is there an ethical justification for doing so?” Public participation has many meanings and names: for example, public engagement, collaborative decision making, public involvement, community engagement, participatory research, and democratic deliberation. Public participation refers to the meaningful involvement of members of the public in public health research, decision making, planning, policy, and practice. Public participation should ensure that participants and decision makers alike are mutually informed and engaged in dialogue and exchange. This requires more than one-way communication to the public (e.g., public services announcements, social media campaigns, or marketing). Decisions that affect the trust of minority and marginalized communities, or that are highly sensitive and divisive, require concerted efforts to involve affected stakeholders. Public participation can enhance the legitimacy, transparency, and justice of decision making and build trust in public institutions. There are many different forms and methods of public deliberation. All share a commitment to the use of balanced, nonpartisan evidence and information to ensure that deliberations are well informed. They provide participants with time for discussion, refection, and co-learning to promote dialogue that identifies the ethical, psychological, social, cultural, and economic impacts and difficult trade-offs of decisions. Public deliberations are also oriented toward finding collective solutions and providing direct feedback to decision makers. Empirical studies and anecdotal evidence show that when it is done well, public deliberation can yield more informed, considered, civic-minded, egalitarian discussions and mutually supported decisions. Appropriate attention needs to be given to citizens who cannot, by reason of young age or cognitive disability, fully participate in public discourse.

SECTION 4. ETHICAL ACTION GUIDANCE FOR POLICY AND PRACTICE IN FUNCTIONAL DOMAINS OF PUBLIC HEALTH

Previous sections of the code have identified core values that provide an ethical mission and identity for the profession and practice of public health (Section 2) and have outlined key considerations that should be contemplated carefully as public health practitioners analyze proposed policies and practices from an ethical point of view (Section 3). Taken together, these core values and components of diligent and deliberative ethical decision making form the foundation for more specific ethical guidance concerning public health functions and activities. The purpose of Section 4 is to highlight ethical issues that arise in distinct functional domains of public health’s service to society and to provide guidance on how those issues should be understood and addressed. Here scientific research, expertise, legal and social authority, public trust, and ethical responsibility meet in the everyday work—the debates, deliberations, and decisions—of public health organizations and practitioners.

Ethical Action Guidance

What does ethical “guidance” mean in the context of Section 4? The action guidance recommendations described below are meant to inform and enlighten the judgment necessarily exercised by public health organizations and practitioners, not to eliminate the need for such judgment or to curtail reasonable and responsible discretion. They are not ethical “rules” that must be followed no matter what. Public health decision makers should presume that these recommendations should be followed, but the facts and circumstances within which a given decision must be made may, from time to time, rebut this presumption. In other words, the recommendations are best understood as ethical starting points, default settings that can legitimately be overridden by specific conditions and factors that impinge on particular policies and decisions. This definition and interpretation of ethical action recommendations is generally in keeping with the use of the term “guidance” familiar in the field of public health and applicable to many kinds of considerations, not only to ethics. Specific ethics guidance in a field as functionally diverse as public health could be organized in many ways. This code has adopted a classification of public health functional areas or “domains” as a clear and recognizable framework for presenting the guidance in this section. While a number of descriptions of key public health functions have been proposed, we use the familiar and well-validated set of functions described by the Public Health Accreditation Board (PHAB). In developing these functional domains, PHAB promulgated accreditation standards for local and state governmental public health entities and set detailed standards within those domains that could be used to assess and evaluate the entities’ performance over time. A parallel classification of functional areas is also useful for organizing ethics action and decision-making guidance, although, as previously noted, this guidance does not set enforceable standards in the manner of accreditation. Note that in at least one instance (Domain 7), we have altered a domain’s name to facilitate analysis of the specific ethical aspects of that particular domain. The functional domains listed in this section are meant to encompass a wide range of public health activities in whatever context they occur, including within government agencies, academia, NGOs, and other community-based organizations.

ACTION GUIDANCE RECOMMENDATIONS

Domain 1: Conduct and disseminate assessments focused on population health status and public health issues facing the community

Public health practitioners and organizations should strive to conduct and disseminate meaningful health assessments focused on population health status and public health issues facing the community. Health assessments, which can exist at the state, tribal, local, or territorial level, generally seek to identify key health needs and issues through systematic, comprehensive data collection and analysis. Community health assessments can be used to guide a strategic planning process, prioritize the development or delivery of services, and assist local communities with activity development. Doing so helps to identify existing community assets (e.g., organizations, partnerships, funding, facilities) and/or deficits (e.g., lack of funding, lack of services, community violence) to promote the health of the community and minimize harms. Findings from health assessments should be disseminated in an ethically responsible manner informed by key stakeholders and community members through an established process.

Ethical policies and practices used to conduct and disseminate assessments of public health status and public health issues facing communities should:

4.1.1. Promote cross-disciplinary collaboration to define community problems and identify causal factors or social determinants of health. Understanding complex and persistent health problems and their determinants is strengthened through multiple nuanced perspectives and disciplinary lenses, always attending to cultural differences among participants with sensitivity and openness. Cross disciplinary collaboration allows individuals with diverse training and experiences to come together to address a common goal. Thus, it is important to understand and recognize the experience and knowledge that each individual brings to the table. Furthermore, such collaboration provides the opportunity to build alliances and partnerships across professions and with communities as a means of developing well-informed, tailored strategies to improve the health of the community.

4.1.2. Engage, empower, and train community members to conduct and disseminate health assessments. Community members’ knowledge and skills are often underutilized. Engaging, empowering, and training community members is important. Doing so builds community capacity and sustainability to improve health outcomes in the long term. Community residents and organizations can help identify, mobilize, and address the strengths and deficits that exist within their communities. This assists them in being more effective partners with public health in health planning and priority setting. Cultural humility and competence are both key in these efforts.

4.1.3. Balance perceived needs with expressed and expert-defined needs to improve community health. There often exists a tension related to balancing the needs and interests perceived by the community with the needs and interests that may be inferred from analyses of data on health care utilization behaviors and with needs and interests perceived by experts and health professionals. It is critical to use multiple forms of data collection and innovative technology and methods to capture the various types of needs germane to the population of interest. In balancing such needs, it must be taken into account that understanding and addressing the health of the community is complex and requires multifaceted approach to assessment with due consideration to the valued role and voice of the affected community in the process. Humility about the limits of expertise is critical. Interpretation of community needs and interests by health professionals should not be given automatic precedence over conflicting points of view. Public health must remain in dialogue with the communities it serves.

4.1.4. Prioritize health problems and disseminate relevant findings. Once community health problems have been identified by key stakeholders through a health assessment, health priorities should be established using various techniques as part of an ongoing process informed by key stakeholders, including community members. Selected priorities should be diffused through agreed-upon dissemination channels and carefully dispersed in a manner that empowers, rather than marginalizes and stigmatizes, the population of interest.

4.1.5. Have safeguards in place so that public health information does not harm individuals or communities. Public health information should not be used to harm individuals or groups. Cultural minorities are often particularly vulnerable. Protocols that are co-developed with those at risk should be in place to protect individual privacy and confidentiality. In small communities and when small numbers are involved, inadvertent personal identification is a possibility and steps should be taken to safeguard against it. Similarly, certain terminology and classification systems can stigmatize or otherwise adversely affect particular groups and communities. Appropriate care should be taken in anticipating public interpretation, misinterpretation, or adverse reaction to public health information and language. Early input about cultural beliefs and language barriers from community leaders, especially those who are members of potentially disadvantaged groups within the community, should be obtained. Dissemination efforts should include means to reach those whose literacy levels are lower than average norms, including children, adults with less education, and those with cognitive impairments.

4.1.6. Promote reflexivity to minimize the influence of biases on the research process. Public health practitioners should engage in ongoing reflexivity and acknowledgment of their positionality in the context of socio-cultural and political influences. Engaging in practices that help characterize those biases and their influence on professional actions and interactions is especially important. Critical self reflection is crucial in examining the types of research questions we construct and pursue, our approach to addressing these research questions, how we identify and engage stakeholders, how we interpret data, and how and to whom we disseminate research findings. Ongoing reflexivity is required to identify less visible or empowered stakeholders or changes in who has a stake in a public health policy, program, or research endeavor.

Domain 2: Investigate health problems and environmental public health hazards to protect the community

When investigating health problems and environmental hazards, it is necessary to collect the information most relevant to characterizing the problem in question and implementing control measures. There are several methods for doing so, all involving some form of active surveillance such as outbreak investigations or surveys of populations and individuals. Problems addressed could be short term, such as communicable disease, or long term, such as cancers associated with environmental exposures. Ethical considerations underlie many decisions involved in any investigation. General issues such as maintaining confidentiality to the extent possible and avoiding conflicts of interest emerge in this domain (as well as in many others). Practical issues related to investigation itself have moral valences. For example, investigators must decide which populations or groups to survey, what data or specimens to collect, how to present the results of the investigation, and how to respond to protect the public. All these activities involve trade-offs between individual privacy and confidentiality and the right of members of the public to know about problems and hazards that could affect them. Attention should be paid to including vulnerable groups (e.g., children and elders) that might be omitted in data collection efforts.

Ethical policies and practices used to investigate health problems and environmental health hazards should:

4.2.1. Detect, recognize, and acknowledge public health threats promptly and efficiently. Given the responsibility public health practitioners carry to protect the public, they must continuously monitor communicable disease and environmental data, periodically conduct risk assessments about potential environmental hazards, and diligently scan the built and natural environments to recognize public health threats promptly. Clues to the presence of public health threats come from varied sources, such as reports of notifiable conditions received from health care providers and labs, disease registries, and anecdotal reports. Decisions to set response thresholds too high or to require additional unnecessary data collection may contribute to a delayed response.

4.2.2. Avoid conflicts of interest that could interfere with the willingness to acknowledge public health threats. Personal or organizational conflicts of interest and conflicts of commitment (e.g., subordinating the obligation to public service to more parochial interests or objectives) must be avoided, as they could influence how a public health practitioner or public health agency acknowledges or responds to a threat. Organizational conflicts can also occur when different agencies want to protect themselves or compete with others in making a response.

4.2.3. Ensure that investigators use resources efficiently and effectively. Public health research and practice frequently involve the use of scarce public resources. Therefore, public health practitioners have an obligation to evaluate each investigation and demonstrate that they have used resources efficiently and effectively.

4.2.4. Ensure data validity, account for the limitations of available data, determine statistical thresholds for defining significance, and take steps to assist others who use the data, including the media and policymakers, so they will not draw inappropriate conclusions regarding cause and effect. The science of epidemiology identifies associations between exposures and disease and assists in determining whether and how these associations represent causal linkages. Those inexperienced in epidemiology may make false assumptions about these associations. This is particularly problematic when done by individuals in policy-making positions. Public health practitioners have a responsibility to collect high-quality data; assess and account for data limitations and potential confounders and modifiers in analyses, conclusions, and reports; and protect against misinterpretation, misrepresentation, and misunderstanding of data and findings. This applies to data from both quantitative and qualitative research.

4.2.5. Give special attention to protecting the privacy and confidentiality of individuals when gathering data, collect only data elements and specimens necessary for disease control or protection, and remove personal identifying information from the data set as soon as it is no longer needed. The nonconsensual nature of many investigative activities requires that public health investigators give special attention to individual privacy and confidentiality. In addition, even aggregated data can be linked to individuals when small numbers and rare demographic features are involved.

4.2.6. Balance the public’s need for information with the possibility that an investigation’s results will create undue burdens or stigma for populations, groups, or individuals or cause other adverse outcomes. Even when aggregated data are being reported, the results have the potential to stigmatize specific populations or create financial risk for individuals in exposed communities, including adverse economic impacts of public health communications such as loss of equity value in homes or increased insurance costs.

4.2.7. Require reporting of findings promptly, especially to individuals and community partners who contributed data to the investigation. Prompt reporting is essential if public health practitioners wish to maintain trust with affected individuals and communities.

4.2.8. Ensure that resulting interventions have the least restrictions necessary to protect the public. After the completion of an investigation, public health practitioners might consider a number of potential responses, all of which are likely to have ethical implications, especially if they involve restrictions on the movements of individuals and populations (e.g., isolation and quarantine) or the use of sanctions to promote desirable behavior and deter undesirable behavior. Public health practitioners have the responsibility to ensure that they use the least restrictive interventions necessary to achieve these goals while reducing the negative effects of these interventions, such as providing adequate food and water for quarantined populations. In addition, public health practitioners have a responsibility to ensure that their recommendations and interventions do not lead to increased health disparities.

4.2.9. Ensure that resulting interventions do not have a disproportionately negative impact on minority or otherwise vulnerable populations (including children and elders) and that there is an effort to enhance the resilience of populations and ecosystems to prevent future harm. Some decisions public health practitioners make involve distribution of scarce resources, such as vaccines, antiviral medications, or ventilators, or imposition of regulations, such as whether health-promoting or health-reducing substances are allowed in specific areas or accessible to specific populations. Public health practitioners have an obligation to work with community stakeholders to develop equitable, transparent systems for distribution and allocation and to ensure that regulatory burdens do not disproportionately affect a minority or vulnerable population.

4.2.10. Empower community members and stakeholders to be active participants in the decision-making process. Public health practitioners can build trust and increase their effectiveness by creating meaningful opportunities for dialogue; being open to unanticipated ideas; attuning themselves to cultural, social, and historical contexts that influence environmental and community health; and being receptive to partnerships. In creating such opportunities, it is not enough to simply schedule meetings or events; it is also necessary to address community background factors or barriers (e.g., lack of transportation, child care services, and translation services) that could limit otherwise desired participation by individuals or groups. Engagement of young and elder people may require special effort.

Domain 3: Inform and educate the public about health issues and functions

Public health practitioners and organizations should strive to provide accessible information about public health issues and functions to the public, including but not limited to political leaders, health care providers, affected populations, and communities. Knowledge is a necessary (but insufficient) input into building healthy homes, workplaces, and communities. Imparting accurate and accessible information requires that public health practitioners and organizations use a variety of communication techniques and teaching methods, remaining sensitive to the diverse audiences they must reach. Doing so helps public health practitioners meet their goals of protecting the health and safety of individuals and fostering the health of communities.

Ethical policies and practices used to inform and educate the public about public health issues and functions should:

4.3.1. Engage all members of the community. Public health activities touch all members of a community, even those who do not recognize the work of the field. All members of a community should know or be made aware of how the efforts of public health practitioners and organizations help to keep them safe and healthy.

4.3.2. Attend to the needs of diverse audiences. Public health organizations serve individuals and communities that vary with respect to demographic characteristics, social and cultural factors, familiarity with public health, and health status. Ensuring that information and education about public health issues and functions are tailored to the needs of diverse audiences is critical to meeting the obligations of health and safety, justice and equity, and inclusivity.

4.3.3. Be honest and accurate. The design, implementation, and outcomes of some public health efforts are straightforward and extremely successful, while others are complex, debated, and uncertain. Public health practitioners and organizations must be honest and accurate when informing and educating the public about actual and potential public health issues and functions, including acknowledging strengths and vulnerabilities about what public health practitioners and organizations know and what they can and cannot do. Honesty and accuracy build public trust, which is essential for the success of most public health efforts. Being honest and accurate in communications with the public also demonstrates respect for the individuals and communities that public health serves.

4.3.4. Portray risk in a variety of ways. Many public health efforts are related to preventing or mitigating risk of poor health outcomes. Yet, risk is poorly understood and misinterpreted by human beings. Risk of an outcome is a combination of the gravity of a potential harm and the likelihood of its occurrence. Public health practitioners and organizations should communicate and educate about risk in a variety of ways (e.g., absolute vs. relative) to avoid overemphasizing or underemphasizing potential harm.

4.3.5. Engage individuals and communities in the development of individual and collective solutions to public health issues. The process of informing and educating the public about public health issues and functions should include messages and processes that empower individuals and communities to participate in the development of healthy communities. Recognition of the interdependence of health and the solidarity needed for solutions to public health problems should be clearly communicated to the public.

4.3.6. Incorporate individual and community experiences and perspectives in the development of individual and collective solutions to public health issues. Informing and educating the public is an important ethical responsibility, but it is incomplete without the openness and willingness of public health practitioners to listen and learn. Neither public health, including its partners and collaborators, nor the communities it serves have a monopoly on scientific knowledge or ethical discernment. Practicing and engaging in ongoing processes of civic learning is fundamental to good public health outcomes.

Domain 4: Engage with the community to identify and address health problems

Public health practitioners and organizations should strive to create meaningful opportunities to involve members of the public in decision making and to build community partnerships that are based on mutual respect, colearning, and shared power. These engagements and partnerships should seek to develop and implement policies and practices that improve population health and reduce health disparities; cultivate resilience, efficacy, and agency among individuals and communities; and promote accountability of and trust in public health institutions. Strong trusting partnerships can serve as a moral compass for routine public health planning and programming and in public health emergencies.

Ethical policies and practices used to engage with the community to identify and address health problems should:

4.4.1. Create meaningful opportunities for ongoing dialogue with stakeholder communities and the public at large to identify health challenges, opportunities, and priorities for action. Meaningful opportunities for dialogue provide people with factual and unbiased information communicated in plain language that the public understands, with adequate time to ask questions, express views, and receive feedback in an environment of mutual respect and reciprocity.

4.4.2. Encourage building public health capability early in life. Work should be done with schools, educators, parent groups, and others to provide improved health education to children. Health literacy in childhood and adolescence is a culturally and political sensitive topic in the United States, but constructive approaches can be developed with the help of educators and parents, among others. Many indicators of child health are alarming, and a life-span perspective indicates that many adult illnesses are affected by health experiences—both medical and psychosocial—early in life.

4.4.3. Be diligent in identifying communities and groups with a stake in health planning and programming activities. Inclusive efforts to identify and reach out to populations with a stake in health planning and programming and to reduce barriers to their participation are essential for public health success, especially including often omitted groups such as young and elder people. Such efforts need to extend beyond health care to other social sectors and involve both recognized community leaders and stakeholders without formal leadership positions.

4.4.4. Convene stakeholders throughout all phases of policy and intervention development, implementation, and evaluation. Inclusion of community members early and throughout health planning and programming can enrich team learning, improve the quality and relevance of health programs and interventions, identify and build community leadership, and strengthen community capacity and vitality.

4.4.5. Be responsive to community perspectives on health challenges, opportunities, and priorities for action. A responsive stance recognizes that communities living with health deficits are often best situated to understand the challenges to and opportunities for better health. Members of these communities have lived experience with social conditions that are detrimental to health and health conditions that can compromise well-being and agency. Ignoring community insights and experience can lead to ineffective programs and wasted resources and cause or compound public mistrust.

4.4.6. Be open to unanticipated ideas for creating positive change. Communities can be a rich source of creative ideas for health improvement, reflecting deeply situated knowledge of where and how people connect, share ideas, and influence positive change.

4.4.7. Be attuned to cultural, social, and historical contexts that influence community health and receptivity to public health partnerships. Attunement to cultural, social, and historical contexts is particularly important when addressing health disparities because communities burdened by excess illness and disease may also be socially disadvantaged by discrimination related to race, ethnicity, age, social class, geography, immigrant status, and sexual orientation and gender identity, among other differences reflected in social hierarchies.

4.4.8. Promote sharing decision making, information, and resources with community partners. Strong community partnerships are built on and sustained by a commitment to equity and respect, demonstrated through shared decision making and collaboration during the planning and implementation of public health interventions. This approach need not abrogate a public health agency’s legal authority or ethical responsibility. Overall, however, the effectiveness of many public health efforts is enhanced rather than undermined by taking a respectful and cooperative approach with affected communities and stakeholders. Not all public health decisions require or are amenable to public participation, but if public health practitioners decide not to involve the public—in order to protect confidential information, to avoid panic, or to avoid giving unfair advantage to certain interested parties, for example—they should be prepared to publicly defend their decision after the fact and demonstrate why it is or would have been unrealistic or counterproductive to make the decision-making process more participatory.

4.4.9. Seek to enhance resilience, efficacy, and agency in individuals and communities. Effective public health planning and programming draws on community resources and creativity and strives to strengthen the capabilities of individuals and communities to respond creatively, preventatively, and proactively to everyday health challenges and emergent health crises.

4.4.10. Build relationships and partnerships based on mutual respect and reciprocity, recognizing the dignity and capability of individuals and the assets and strengths of the community. Community engagement and partnerships built upon these ethical guideposts can promote the accountability of and trust in public health.

Domain 5: Develop public health policies and plans

Public health practitioners and organizations should strive to develop meaningful, effective, and practicable health policies and plans aimed at improving population health. Public health measures are most properly applied when they are based on the best available scientific evidence and incorporate the knowledge gained through previous public health activities and community engagements. Efforts to promote the public’s health must be applied in a manner that incorporates feedback from the affected communities, local values and customs, and appropriate measures to avoid harm to or stigmatization of community members. Moreover, it is imperative that public health practitioners implement measures that will respect the privacy and personal autonomy of affected individuals and will minimize infringement upon personal liberties and adverse health or social outcomes.

Ethical policies and practices used to develop public health policies and plans should:

4.5.1. Be designed with input from community members and be sensitive to local values and customs. Public Health policies and plans will be most effective when community members participate in their development. By encouraging community participation, public health practitioners will ensure that public health plans and policies are relevant and feasible within the communities in which such plans and policies will be implemented. Specifically designed intergenerational conversation may allow richer conversation bridging past, present, and future.

4.5.2. Incorporate scientifically vetted, research-based data to the fullest extent possible. Valuable financial and personnel resources are used in the development and implementation of public health policies and plans. Therefore, care should be exercised in ensuring that the bases of such policies and plans have been rigorously tested and proven viable.

4.5.3. Consider the experiences of designing and implementing these types of policies and plans within the community in question, as well as in other similar communities, and incorporate lessons learned from these experiences into future design and implementation efforts. Public health practitioners should seek to learn from their own and others’ public health efforts in the development of public health policies and plans to avoid pitfalls and improve upon successes. In this way, practitioners will make best use of limited resources.

4.5.4. Promote policies that enhance community health and well-being and collaboratively respect the privacy, dignity, and civil liberties of individuals and communities affected by the policies and plans. Public health policies and plans are inherently focused on improving health across populations rather than focusing on any one individual. Special care should be taken to ensure that individuals and communities are respected and afforded appropriate ethical consideration during the development and implementation of such policies and plans.

4.5.5. Avoid unintentional stigmatization of specific groups within the community. Public health policies and plans can inadvertently bring unwanted or undue focus on certain individuals or groups. This should be avoided to ensure protection of privacy and prevent embarrassment and/or social ostracism.

4.5.6. Aim to improve the health of – and health care for – all vulnerable populations impacted by existing disparities and inequities. Health and health care disparities are commonplace in our society. In improving the health of a population, the concept of social justice renders it imperative that public health practitioners recognize the unmet needs of vulnerable populations, including children and elders, and seek to eliminate existing inequities.

4.5.7. Consider and, where possible, address determinants of health that reside outside a person’s genetic endowment and personal behaviors, including the circumstances in which people grow, live, work, and age. These determinants might include individual resources, community resources, hazardous exposures, and opportunity structures. Appropriate measures must be taken to minimize the impact of inadequate individual or community resources by ameliorating shortcomings or inequities to the extent possible. Moreover, after a careful analysis of the social and environmental determinants of health within the community, appropriate remedial efforts must be taken to prevent further harms precipitated by such factors.

4.5.8. Reduce or eliminate negative impacts on communities and the environment, particularly as these negative impacts tend to be disproportionately experienced by individuals already faced with health inequities. Public health practitioners must be sensitive to the impact of identifiable health determinants on all members of society, noting that vulnerable populations may well be most affected in these circumstances. In response, educational, social, and public health measures must be appropriately tailored to meet the needs of specific population audiences.

4.5.9. Ensure that reasonable alternative options are considered and evaluated and that final public health policies and plans are designed to most effectively accomplish stated goals while minimizing the potential for harm. Attention must be paid to potential undesirable consequences such as limitation of individuals’ autonomy or personal liberties, potential breaches of privacy, and/or social alienation of specific population groups. It is incumbent upon public health practitioners to draw on their own and others’ expertise and previous experiences to determine the best course of action in view of potential negative consequences.

4.5.10. Include impartial mechanisms for assessing the ethical appropriateness of public health policies and plans after they have been implemented, as well as mechanisms for adjusting such policies and plans to ensure continued adherence to ethical standards. All public health interventions must be subject to systematic ethical reviews with the intent of ensuring that the benefits of the interventions are achieved in a way that minimizes burdens on the individuals and communities being served. These ethical reviews should incorporate frank discussions involving representatives of the community, specific community populations (where applicable), and public health leaders.

4.5.11. Ensure that public health policies and plans are sensitive to race, ethnicity, sex, sexual orientation, gender identity, and other unique characteristics of individuals affected by the policies or plans. Public health measures must consider the culture, language, and health beliefs of all individuals they aim to serve. Public health practitioners should, in the development of public health plans and policies, recognize that individual community subpopulations may express specific needs, beliefs, and preferences. These factors should be incorporated to the greatest extent possible to facilitate a sense of inclusion while simultaneously enhancing the efficacy of public health interventions.

Domain 6: Enforce public health laws

Governmental regulatory agencies should partner with public health practitioners and organizations to protect individual and population health, safety, and welfare by ensuring that individuals and businesses abide by public health laws. Government agencies are authorized to act to protect and improve health by enforcing regulations aimed at implementing and managing practices that promote health, protecting against injury or disease, ensuring the administrative capacity of organizations carrying out public health functions, and monitoring and responding to health and safety issues within the jurisdiction. Enforcement of public health laws provides government agencies with an opportunity to build trust with the community, improve the accountability of organizations whose actions impact health, and reduce health disparities. Enforcement of public health policies, or lack of enforcement, may itself serve either to mitigate or to reinforce existing health disparities; care should be taken to avoid the latter. Government public health authorities have a duty to enforce public health laws effectively to fulfill the values and goals of public health.

Ethical policies and practices used to enforce public health laws should:

4.6.1. Be established by government authorities authorized to enforce public health laws. Government officials are obligated to address the ethical issues associated with public health laws. Ideally, ethical considerations are examined and deliberated during the drafting of public health laws and regulations.

4.6.2. Mitigate health disparities. Public health law enforcement should aim to improve the health of individuals in underserved communities and those experiencing the greatest disparities in health. During implementation of public health laws, regulatory bodies should use scarce resources efficiently to produce just outcomes, with a fair and equitable distribution of resources.

4.6.3. Avoid infringing on individual liberties and privacy to the extent possible. Public health typically focuses on population health rather than individual health. However, the pursuit of population health in any specific context or setting should be accompanied by respect for the rights of the individuals who make up that population. Enforcement of public health laws and implementation of public health measures should adhere to due process of law in protecting individuals’ rights to privacy, liberty, and autonomy. When individual interests and rights must be infringed, the least restrictive effective means should be employed, and accessible complaint and restitution mechanisms should be in place.

4.6.4. Encourage participation by nongovernmental entities. Participation by nongovernmental entities in both the drafting of public health law and implementation of regulations (e.g., built-in comment periods and draft iterations before final rules are released) will promote more effective implementation. True partnership during the drafting and implementation phases with nongovernmental entities working within communities will ensure that regulations fulfill their intended purpose.

4.6.5. Include appropriate publication of the public health law and educate the public on how to comply with both the letter and the spirit of the law. Nongovernmental public health authorities can provide support in educating the public about health laws.

Domain 7: Promote improved access to social resources conducive to health and health care

Public health practitioners and organizations should strive to promote and improve both population and individual health using multiple strategies based on epidemiological, medical, and social scientific research. The ethical action guidance offered below addresses four areas in particular: (1) health information and literacy, (2) social determinants and inequities that limit the capabilities of individuals and groups to achieve reasonable levels of health and functioning, (3) equitable access to public health services, and (4) equitable access to clinical medical and nursing care.

Ethical policies and practices used to improve access to social resources conducive to health and health care should:

4.7.1. Encourage collaboration with other health experts, professional associations, and civic groups to improve health care finance and delivery. Achieving universal, equitable access to key resources conducive to health and health care requires the engagement of all health-associated sectors, including public health. Public health organizations and practitioners have obligations to ensure equitable access to clinical medical nursing, and ancillary care. Through research and reasoned argument, public health practitioners and organizations should assist in the promotion of adequate geographical coverage of essential health and nursing services in those areas where such physical access is lacking or unreasonably expensive or inconvenient. Public health organizations should address the situation and needs of those who lack access to affordable health insurance coverage, either in the private insurance marketplace or through publicly funded entitlement programs. Finally, public health practitioners should be vigilant concerning situations in which access to clinical medical services is blocked by the unwillingness of providers in a particular specialty or region to provide care. Public health organizations in some cases may be able to offer a safety net in such situations or should seek new ways to provide access to individuals whose personal interests or needs are marginalized or stigmatized.

4.7.2. Assist, through research and reasoned argument, the process of informing policymakers and the public concerning the requirements of a sustainable health insurance system that provides comprehensive and universal coverage. Currently, one of the most serious health risks in America is widespread factual misunderstanding about how sustainable social insurance systems function and what their requirements are, such as a shared sense of solidarity and the equitable sharing of financial risk. Public confusion and controversy about these matters is a major political obstacle to just health reform and to achieving the ethical goal of equitable access to health care. Educational efforts by public health organizations and practitioners in this area are no less ethically important than those pertaining to tobacco use, substance abuse, nutrition, or obesity.

4.7.3. Base health promotion efforts on respect for the dignity and capability of individuals, not on strategies of stigmatization or on appeals to motivations of fear, disgust, and shame. Clearly, public health must engage in health promotion and behavior modification efforts such as providing information, health education, and reasonable persuasion addressed to people’s values and interests. Other health promotion efforts aimed at eliciting negative emotion and affect are also widely used and may be effective, but public health practitioners should exercise caution when following such strategies. The behavioral gains may be short lived, and the cost of using personal stigma and shame to deter unhealthy behaviors can be high in terms of the many other values public health stands for and promotes. The ethical importance of discouraging deleterious health behaviors does not justify stigmatizing individuals or groups engaging in those behaviors. Negative messaging cannot be controlled in society and culture and will likely redound to individuals and groups. Respectful messaging can help minimize stigma. Strategies based on stigmatization are likely to generate mistrust of public health institutions and professionals, thereby undermining efforts to gain public cooperation at other times.

4.7.4. Develop programs to promote health that supplement individual informed choice and access to clinical and preventive care by attending to the social environment. Public health efforts that address only the biological risk factors affecting populations and seek to provide only individual access to health insurance and clinical services are ethically necessary but insufficient. Improving access to the social environmental conditions and resources that enable individuals and groups to be healthy is a key component of the ethical service that public health should provide, and often does provide, to society.

4.7.5. Improve access to community-based public health services and outreach to underserved populations and those most affected by health disparities. Access to community-based services, including many vital preventive, harm reduction, counseling, and other programs, is an essential part of the social service and health care safety net. Public health should coordinate efforts to integrate health, mental health, and social services more effectively to meet the comprehensive needs of all populations, especially those underserved and most affected by health disparities.

4.7.6. Recognize and act upon the fact that the ethical obligation to provide access to health care is not limited to persons with citizen status only. The ethical obligation of public health to promote health and safety does not always entail proactive cooperation with law enforcement agencies. Public health problems often affect all members of a population or community, irrespective of individual citizenship status. Citizenship status can be irrelevant to fulfilling public health responsibilities (e.g., ensuring a safe work environment or the safety of the food production system). Prioritization of legal action to address immigration status can undermine implementation of policies that seek to protect the public’s health. Public health law and ethics both recognize the role of health institutions and professionals in safeguarding the privacy of all community members, which is often a necessary precondition for public health officials to be trusted with sensitive information they need to protect and promote the public health.

4.7.7. Engage in program planning to increase the capacity of the public health infrastructure to respond to increased need and to maintain equitable access to services. This is particularly important in anticipation of a growing population of uninsured, underinsured, or medically indigent persons. Policy and funding advocacy for maintenance and support of this infrastructure is not only ethically permissible but required in times of systemic, inequitable access to health care.

Domain 8: Maintain a competent public health workforce

Public health leaders, researchers, and organizations cannot protect the public’s health and perform their ethical obligations to society unless a well-trained, competent, and well-motivated workforce exists as a resource to support them. Ultimately, society must support this vital resource and provide the education and public funding necessary for its maintenance. Nonetheless, the field of public health itself and public health organizations must also do their part to maintain a competent workforce. This domain of public health has ethical significance because the ethical goals of public health cannot be met unless the work of public health is well done.

Ethical policies and practices used to maintain a competent public health workforce should:

4.8.1. Provide ongoing training in all relevant areas to the workforce. Ongoing training of public health practitioners will be most effective if done with an eye toward career progression and building leadership capacity.

4.8.2. Promote education and training of public health workers from diverse social, cultural, economic, and other backgrounds and communities. It is ethically advisable to recruit into the public health workforce individuals from groups and communities disproportionately affected by public health problems. Over time, this will build better rapport between public health workers and those they serve.

4.8.3. Support access to public health education and training and provide financial assistance based on need. In-service training and career development should be available to public health practitioners and students regardless of their ability to pay. Public health practitioners have an ethical obligation to stay current with the most reliable knowledge in their fields and should not be deterred—or forced to make undue personal or family sacrifice—through the prospect of incurring burdensome educational debt. Here training programs include not only degree-granting programs but also conferences, workshops, and other professional development opportunities. Public health organizations that may sponsor these programs should set fees in accordance with this ethical consideration.

4.8.4. Provide adequate institutional and professional support to enable competent performance. In public health, as in other fields, there is a strong connection between individuals’ competent actions and the context within which they practice. Public health leaders and organizations should recognize the nature and significance of supportive contexts and arrange for individual public health practitioners to be adequately supported. Without such support, competent performance is not a reasonable ethical expectation.

4.8.5. Encourage broad and creative thinking about educational and training needs. It is important to be aware of “real-world” environments and communities in which public health practitioners work and how that affects their effective competence. Training should also be provided in communications skills and political acumen related to public health work. Finally, attention should be paid to often underutilized educational models such as apprenticeships and mentoring. Such intergenerational learning opportunities can enhance learning about the evolution of problems over time and increase the imaginative space of solutions.

4.8.6. Incorporate ongoing evaluations of educational and training programs/activities. Scientific knowledge and social knowledge are essential to public health programs. These bodies of knowledge are dynamic, and continuing education is essential. This not only will put public health practitioners in a position to be more effective but will also help them remain alert to the emergence of new public health issues and novel challenges.

4.8.7. Provide ethics education as a central part of public health education and ongoing training. Public health practitioners should be trained to recognize and articulate the ethical aspects of their work. They should be trained in deliberative decision-making processes and aware of the need to evaluate the ethical implications of their interventions and programs.

Domain 9: Evaluate and continuously improve processes, programs, and interventions

Continuous quality improvement (CQI) approaches include a range of techniques but have at their heart cycles of plan-do-check-act. CQI submits plans, policies, and procedures to a cycle (with multiple iterations, if necessary) of taking action, evaluating the action, and modifying the plan or policy accordingly. The cycles can be quite short (a matter of days or less) or long term (months or even years). CQI is appropriately a part of public health accreditation processes. Many resources are available to guide efforts. Ethical issues are imbedded in the entire process based on the overarching value of attempting to provide constantly improving services to the public and other stakeholders. Many of the specific issues associated with components of the cycle (planning, investigation, research, action) are included in other domains.

Ethical policies and practices used to evaluate and continuously improve processes, programs, and interventions should:

4.9.1. Involve a commitment to a continuous improvement process for all essential programmatic components. Continuous quality improvement is essential to public health because it promotes vigilance in staying responsive to ever-changing community and organizational needs and excellence in programmatic response. Moreover, it relates to other critical aspects of scientific method such as hypothesis testing, strategic planning, general program improvement, enhancement of education, and experiential learning.

4.9.2. Engage a wide spectrum of stakeholders in the improvement process. Public health belongs to everyone, and everyone has some responsibility for its ongoing improvement. Stakeholder analysis is a key aspect of CQI. For specific CQI projects, omitting relevant stakeholders accidentally or intentionally can diminish the likelihood of positive outcomes.

4.9.3. Develop as appropriate strategic plans with measurable goals for essential program components. Strategic planning should include CQI, as all strategic plans need to adapt to changing internal and external circumstances. Strategic plans that are static and not incorporated into the life of the organization are likely to be a waste of organizational and social resources.

4.9.4. Incorporate regular reviews of all essential program aspects in the context of specified goals. Comparable and appropriate metrics should be used to evaluate community health programs in relation to other critically important activities. Triggers for new CQI cycles should be as transparent as possible.

4.9.5. Assess the environment for improvements in evaluation approaches. CQI methods are constantly changing, for example using new information technology approaches such as collection and mining of increasingly large data sets to find patterns that would otherwise go undetected. Hence, CQI processes should themselves be subject to CQI methodology.

4.9.6. Evaluate the quality improvement process on a regular basis. CQI processes should be built into performance metrics. For example, one can ask questions such as the following: What improvements in service quality or outcomes resulted from the human and financial resources allocated? What were the opportunity costs associated with CQI processes?

4.9.7. Involve an investment in relevant innovations in approaches to providing feedback through learning interventions. CQI promotes organizational and individual learning. Translating what is learned through CQI into ongoing individual, community, and organizational practices is essential. As appropriate, sharing with other organizations should be a key value to enhance the benefit of what is learned in one place, often at a high cost to that organization.

Domain 10: Contribute to and apply the evidence base of public health

Public health practitioners and organizations should strive to contribute to and use credible evidence to promote and improve population and individual health. This requires two essential conditions: First, public health practitioners must have basic skills to assist them in making sound judgments with respect to the quality and applicability of evidence. Second, public health scientists and researchers must possess high-quality skills in research design, data analysis, and interpretation. Together, creating and applying evidence in public health practice helps public health practitioners and organizations meet their obligation to protect the public’s health and promote human flourishing.

Ethical policies and practices used in contributing to and applying the evidence base of public health should:

4.10.1. Employ the best available evidence to guide public health work. Public health is a multidisciplinary field that addresses complex and varied issues requiring a variety of types of evidence. Determining what constitutes the best available evidence requires practitioners and organizations to consider findings from multiple disciplines as well as the lived experience of affected communities. In addition, it requires evaluation of the strength and appropriateness of various findings with respect to the context and character of the problem at hand. Use of best available evidence helps public health practitioners and organizations meet their obligations related to fidelity and responsibility, effectiveness, inclusivity, and responsible use of limited public resources.

4.10.2. Emphasize that scientific evidence comes in different forms with different degrees of certainty and probability. Public health evidence should be presented with a degree of certainty that is warranted by its underlying methodology and completeness. This applies to internal communications among public health practitioners as well as to external communications with policymakers and the public.

4.10.3. Consider evidence from multiple disciplines. Public health organizations address a complexity of distal determinants and a variety of the proximate determinants of health. This requires consideration of evidence from clinical and laboratory sciences, social and behavioral sciences, epidemiology, and the lived experience of affected communities. Consideration of the full body of evidence leads to more inclusive and effective interventions. Interdisciplinary and transdisciplinary approaches can enhance more basic multidisciplinary and cross-disciplinary approaches by intensifying the intergenerativity of boundary-spanning thinking and action.

4.10.4. Evaluate the strength and appropriateness of different types of evidence. The strength and appropriateness of evidence depend on the public health problem and context at hand. Some problems are new and require indirect or analogous evidence at the start; others are perennial and require a critical examination of often conflicting findings. Evaluation of evidence requires an understanding of the relative merits of various research methods, scientific disciplines, and types of data available given the specific public health problem being addressed. Using the strongest and most appropriate evidence available helps public health practitioners and organizations achieve their obligations of fidelity and accountability, as well as transparency.

4.10.5. Recognize and acknowledge when evidence is changing or incomplete and when assumptions or contexts change the relevance of evidence. Some public health problems are new or changing in such a way that evidence is unavailable or rapidly developing and changing. Identifying and communicating gaps in knowledge—knowing and communicating what we do not know—is an important aspect of judging strength of evidence, being accountable and transparent, and building public trust.

4.10.6. Involve an investment of resources in collecting ethically and methodologically sound evidence. Where evidence is lacking or conclusions are unclear, public health practitioners and organizations should both gather sound evidence that strengthens the ability to identify and address public health problems and support the collection of such evidence by others. When methods are inadequate for producing sound evidence, public health practitioners and organizations should invest in developing methods that meet the needs of public health science. When producing evidence, public health practitioners and organizations should comply with disciplinary ethics standards and expectations, including research integrity, ethical research practices, protection of human and animal subjects, and responsible communication of results. Investing in the production of sound evidence allows public health practitioners and organizations to honor their obligations to fidelity, effectiveness, and responsible use of scarce resources.

Domain 11: Maintain administrative and management capacity

Ethical standards of conduct apply directly to the decisions and actions of individuals at all levels of practice in public health. Because organizational leadership can create a climate that encourages or inhibits ethical conduct and practice, additional ethical expectations hold for individuals with administrative and managerial authority and responsibility. Sustaining an organization’s administrative and managerial capacity is a part of public health ethics. The guidance within this domain pertains particularly to those in leadership roles who shape and maintain public health organizations and their capacity to carry out a public health mission in service to society. Public health ethics is attentive to the important interaction between individual character and activity on the one hand and organizational culture and support on the other. Individuals with ethical integrity make good organizations function, but an organizational environment and culture are also needed to support individuals with ethical integrity—to recruit them, enable them, and retain them.

Ethical policies and practices used to maintain administrative and management capacity in public health organizations should:

4.11.1. Provide for the recruitment, retention, and career development of highly qualified public health practitioners in managerial roles. The managerial capability of an organization depends upon the quality, experience, and professional expertise of those who fill leadership and managerial roles. Analytic reasoning skills, the ability to recognize ethical and value dimensions of public health practice, and an ethical vision for oneself and the organization should be among those qualities sought in managers and leaders in public health.

4.11.2. Ensure nondiscriminatory personnel practices in recruitment, hiring, retention, and promotion. Making leadership offices in public health equally open to all based on competitive merit is both a standard of ethics and a pragmatic practice that will maintain the quality of the public health profession over time.

4.11.3. Incorporate periodic financial disclosures and prohibitions on conflicts of interest, including perceived conflicts of interest applicable to all directors, management, staff, and the organization itself. The misuse of office or position for personal financial gain or other types of unfair advantage must not be permitted. In addition, public health organizations and authorities must have policies and procedures in place to avoid creating actual or perceived conflicts of interest.

4.11.4. Maintain an organizational culture that promotes ethical integrity and equal dignity and respect in relationships among staff, with the outside community, and with the beneficiaries of the organization’s public health programs and services. This is one component of the important objective of bringing about tangible change in the culture and practice of organizational management. Key values that the public health profession and public health organizations should promote and profess in the broader community should also be reflected within the culture, policies, and conduct of the organization, including incorporating into risk management ethical considerations that encourage transparency while ensuring individual privacy.

4.11.5. Establish employee performance standards and evaluations based on ethical standards of conduct and public health values. By including goals and objectives based on public health values in performance evaluations, managers can encourage employees to incorporate ethical considerations and conduct into their daily work.

4.11.6. Provide resources for periodic education and staff training concerning ethical issues that arise throughout the organization’s work, both among staff and in the broader community. If individuals, including employees and leadership, and organizations are to be held accountable for compliance with ethical standards of conduct, it is ethically incumbent on organizations to provide the necessary learning, professional development, and support.

4.11.7. Establish formal structures, such as ethics committees, to address and resolve ethical disagreements and challenges and to enhance organizational ethics and decision making. Formal structures such as ethics committees that include community stakeholders and employees can create a climate of ethical performance by promoting open, transparent decision making while building community trust.

4.11.8. Incorporate ethics into quality improvement and performance management policies and activities. Quantifiable performance metrics should be attentive to the effects policies, programs, and practices have on equity, public trust, and public perceptions of the organization; respect for vulnerable individuals; and engagement with vulnerable communities.

Domain 12: Maintain capacity to engage with public health governing entities

Legally authorized public health governing bodies, agencies, and professionals are granted authority to develop and promote public health programming. These individuals and groups within the government can determine funding for public health activities and therefore have a duty to maintain open and responsive communication with the public. Similarly, nongovernmental public health organizations have a duty to ensure ongoing engagement with public health governing bodies, agencies, and individuals; to promote the interests of the public; to ensure transparent justification of government policies, regulations, and activities; and to influence the development and maintenance of public health infrastructure. Organizations familiar with jurisdictions’ needs should participate in public health law and regulation drafting processes to ensure that needs are met ethically and equitably.

Ethical engagement with public health governing bodies should:

4.12.1. Promote constructive communication among the public, nongovernmental entities, individuals, and groups that draft and enact public health legislation and individuals and groups within the government that develop and implement public health activities. Offering public comment periods for proposed legislation and regulation by the government and participation in comment periods by all who can participate (e.g., NGOs, the public, and individuals and groups within the government tasked with carrying out the government’s public health programming) will aid effective execution of public health laws by setting reasonable operational goals and clarifying roles and responsibilities. This includes cross-government communication within, between, or among local, state, and federal governing bodies.

4.12.2. Empower nongovernmental entities to engage in open dialogue with the government. Nongovernmental entities are often positioned close to the communities and populations they serve and can quickly identify how those communities and populations might be affected by proposed or enacted regulations as well as government public health activities. Therefore, those entities should communicate with the government regarding how government regulations and activities are affecting, both positively and negatively, the populations served by the entities.

4.12.3. Promote openness among the government, nongovernmental entities, and the public regarding resource allocation and performance improvement. If the government is to allocate resources efficiently and effectively, particularly resources funded by taxpayer dollars, the government and nongovernmental entities should discuss expectations and reality regarding resource allocation when the government is implementing interventions as well as the steps the government is taking to improve efficiency and effectiveness.

4.12.4. Encourage policy development to protect the public’s health. Improvements in public health over the past century are in large part attributable to the development of policies, ordinances, and statutes aimed at improving living and working conditions and safety, stymieing the spread of disease, and ensuring access to health care. Nongovernmental public health entities have an obligation to collaborate with the government to develop policies and regulations that promote health and to support governing entities in advocating for public health.

REFERENCES

1. By public health practitioner, we do not mean only those who work with governmental public health agencies, but also all those persons who are involved in the development, implementation, evaluation, and study of practices and policies designed to advance public health.
2. Thomas JC, Sage M, Dillenberg J, Guillory VJ. A code of ethics for public health. Am J Public Health. 2002;92(7):1057–1059.
3. Public Health Accreditation Board. Standards and measures, version 1.5. Available at: http://www. phaboard.org/wp-content/uploads/SM-Version-1.5-Board-adopted-FINAL-01-24-2014.docx.pdf. Accessed April 2, 2019