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Introducing poses two special challenges. First, it is a relatively new field that combines public health and practical ethics. Its unfamiliarity requires considerable explanation, yet its scope and emergent qualities make delineation difficult. Moreover, while the early development of public health ethics occurred in a western context, its reach, like public health itself, has become global. A second challenge, then, is to articulate an approach specific enough to provide clear guidance yet sufficiently flexible and encompassing to adapt to global contexts. Broadly speaking, public health ethics helps guide practical decisions affecting population or community health based on scientific evidence and in accordance with accepted values and standards of right and wrong. In these ways, public health ethics builds on its parent disciplines of public health and ethics. This dual inheritance plays out in the definition the U.S. Centers for Disease Control and Prevention (CDC) offers of public health ethics: “A systematic process to clarify, prioritize, and justify possible courses of public health action based on ethical principles, values and beliefs of stakeholders, and scientific and other information” (CDC 2011). Public health ethics shares with other fields of practical and professional ethics both the general theories of ethics and a common store of ethical principles, values, and beliefs. It differs from these other fields largely in the nature of challenges that public health officials typically encounter and in the ethical frameworks it employs to address these challenges. Frameworks provide methodical approaches or procedures that tailor general ethical theories, principles, values, and beliefs to the specific ethical challenges that arise in a particular field. Although no framework is definitive, many are useful, and some are especially effective in particular contexts. This chapter will conclude by setting forth a straightforward, stepwise ethics framework that provides a tool for analyzing the cases in this volume and, more importantly, one that public health practitioners have found useful in a range of contexts. For a public health practitioner, knowing how to employ an ethics framework to address a range of ethical challenges in public health—a know-how that depends on practice—is the ultimate take-home message.

While “public health” has been defined as what society does to “assure the conditions for people to be healthy” (Institute of Medicine 2003, xi), public health is a “systematic process to clarify, prioritize, and justify possible courses of public health action based on ethical principles, values and beliefs of stakeholders, and scientific and other information” (Schools of Public Health Application Service 2013). Despite several important characteristics that distinguish public health from clinical medicine, from the beginning, public health ethics borrowed heavily from clinical ethics and research ethics (see Chap. ). In the 1980s, with the onset of the AIDS epidemic and unprecedented advances in biomedicine, the inability of clinical ethics to accommodate the ethical challenges in public health from existing frameworks led pioneering ethicists to reframe and adapt clinical ethics from an individual and autonomy focused approach to one that better reflected the tension between individual rights and the health of a group or population (Bayer et al. 1986; Beauchamp 1988; Kass 2001; Childress et al. 2002; Upshur 2002). Others called for public health ethics to emphasize relational ethics and political philosophy (Jennings 2007). More recently, some authors have suggested outlining foundational values from which operating principles for public health ethics can be articulated only after careful consideration of the goals and purpose of public health. This approach would require us to establish a clear definition of the moral endeavor of public health as a field (Lee 2012) and construct an ethical framework stemming from the nature of it (Dawson 2011).

There has been much discussion of resource allocation in medical systems, in the United States and elsewhere. In large part, the discussion is driven by rising costs and the resulting budget pressures felt by publicly funded systems and by both public and private components of mixed health systems. In some publicly funded systems, resource allocation is a pressing issue because resources expended on one disease or person cannot be spent on another disease or person. Some of the same concern arises in mixed medical systems with multiple funding sources.

Ethical issues surrounding public health policy and practice aimed at disease prevention and control often involve conflicting rights and values. Such conflicts partly arise from tension between individual and community interests or tension involving cultural beliefs and practices. This chapter outlines how such conflicts and tensions arise in the context of disease prevention and control by exploring ethical issues associated with mandatory treatment and vaccination, disease screening and surveillance, diseases prone to stigma, access to care, health promotion incentives, and emergency response.

Chronic diseases include conditions such as heart disease, stroke, cancer, diabetes, respiratory conditions, and arthritis. In high-income countries, chronic diseases have long been the leading causes of death and disability. Globally, more than 70 % of deaths are due to chronic diseases, in the United States, more than 87 % (World Health Organization [WHO] 2011). Almost one in two Americans has at least one chronic condition (Wu and Green 2000). Aside from the cost in terms of human welfare, treatment of chronic disease accounts for an estimated three quarters of U.S. health care spending (Centers for Disease Control and Prevention [CDC] 2012). Chronic diseases directly affect overall health care budgets, employee productivity, and economies. Globally, noncommunicable diseases account for two-thirds of the overall disease burden in middle-income countries and are expected to rise to three-quarters by 2030, typically in parallel to economic development (World Bank 2011). Of particular concern to many low- and middle-income countries is that threats to population health occur on two fronts simultaneously: “In the slums of today’s megacities, we are seeing noncommunicable diseases caused by unhealthy diets and habits, side by side with undernutrition” (WHO 2002).

Environmental health and occupational health and safety have long been established subfields of public health research, policy, and practice (Frumkin 2010). More so perhaps than areas such as infectious disease or health promotion, environmental and occupational health remind us that the health of a society is profoundly affected by its economic system and economic development. Today, the environmental health field is largely concerned with a human-made (anthropogenic) environment brought about by urbanization, the extraction of natural resources, industrial manufacture, the physical separation of home and workplace, and the transportation systems needed to support this mode of economy and pattern of living. Economic development alters the natural environment and sometimes harms ecosystems in terms of the humanly useful services they provide, their diversity, and their resilience. We are coming to understand that all of this has significant consequences for human health.

Public health practitioners attempt to identify and then remove, or at least reduce, threats of harm. However, harm does not affect everyone in the same way. Some people and communities are resilient, whereas others are more susceptible to potential harm. Much public health work is carried out by, or on behalf of, governments. Where people or communities are at great risk of harm, government has a clear and firm responsibility to protect its citizens. One way of describing a potential source of such a risk of harm is to focus on the idea of . This introduction explores the concept of ‘vulnerability’ and the role that it may play in public health.

There is a long tradition of global collaboration in biomedicine and public health. Examples range from medical outposts in rural communities run by foreign missionaries (Good 1991) to the early infectious disease programs of the Rockefeller Foundation (Fosdick 1989) and from medical services and training programs for indigenous populations set up by colonial authorities (Marks 1997) to the Pan American Health Organization (PAHO) established by a collective of sovereign governments (Cueto 2007).

Having a scientific basis for the practice of public health is critical. Research leads to insight and innovations that solve health problems and is therefore central to public health worldwide. For example, in the United States research is one of the ten essential public health services (Public Health Functions Steering Committee 1994). The , developed by the Public Health Leadership Society (2002), emphasizes the value of having a scientific basis for action. Principle five specifically calls on public health to seek the information needed to carry out effective policies and programs that protect and promote health.