In 2023, cholera made a devastating comeback. The World Health Organization reported that global cases rose by 13 percent and deaths surged by a staggering 71 percent compared to the previous year. The disease spread to 45 countries, up from 35 in 2021, with 38 percent of reported cases affecting children under five years old.
Cholera thrives in conditions of poverty, inequity, and weak health systems. Its resurgence brings up difficult questions that public health ethics seek to answer, from how to allocate limited vaccines to how to ensure fair access to treatment.
For those pursuing a career in public health or developing expertise through advanced degree programs, understanding public health ethics is critical for addressing real-world public health challenges like the cholera crisis.
What Is Public Health Ethics?
Public health ethics focuses on the moral principles that guide public health professionals, policymakers, and organizations in their actions, policies, and decisions related to improving the health of populations.
Unlike clinical ethics, which deals with individual patient care, public health ethics operates on a broad scale, addressing the health needs of communities, nations, and the global population.
At its core, public health ethics seeks to clarify what it takes to promote health and well-being while respecting individual rights and societal needs.
Public Health Ethics Principles
Principles at the core of public health ethics include the following:
Beneficence
Beneficence emphasizes the obligation to act in ways that promote the health and well-being of populations. This includes implementing vaccination programs, improving access to clean water, and launching public health campaigns to reduce smoking.
During the COVID-19 pandemic, for example, beneficence guided the rapid development and distribution of vaccines to protect as many people as possible.
However, the principle of beneficence raises questions: What happens when the well-being of the majority conflicts with the rights of a minority? How do we prioritize which health interventions to fund?
Non-Maleficence
While beneficence focuses on doing good, non-maleficence means avoiding harm. This principle is a reminder that public health interventions, however well-intentioned, can have unintended consequences.
For instance, quarantines during disease outbreaks can save lives by preventing transmission, but they can also cause economic hardship and psychological distress. Public health professionals need to carefully weigh the benefits of an intervention against its potential harms and seek the least harmful approach.
Justice
The principle of justice emphasizes the importance of distributing the benefits and burdens of public health policies. This is particularly crucial when addressing health disparities, which often disproportionately affect marginalized communities.
For example, during the previously mentioned cholera resurgence of 2023, low-income countries faced significant challenges in accessing vaccines and clean water, while wealthier nations had more resources to protect their populations. Public health ethics calls for addressing these inequities by prioritizing the needs of the most vulnerable and ensuring that everyone has a fair chance at good health.
Autonomy
Autonomy refers to the importance of respecting individuals’ rights to control their own health choices. This principle is especially relevant in situations such as mandatory vaccination or quarantine policies, where the needs of the community may conflict with individual freedoms.
For example, during the Ebola outbreak of 2013-2016, public health officials had to balance the need to isolate infected individuals with the ethical obligation to respect their autonomy and dignity. Public health ethics encourages transparency, communication, and community engagement to ensure that individuals feel respected and empowered in the decision-making process.
Social Justice
Social justice goes beyond justice to focus on the root causes of health disparities. It calls on public health professionals to confront issues such as poverty, discrimination, and unequal access to healthcare and work towards creating fairer systems that give everyone a chance to live a healthy life.
During the COVID-19 pandemic, for instance, the principle of social justice guided efforts to ensure underserved communities and those with limited access to healthcare received equal access to vaccines.
Reciprocity
Reciprocity recognizes the obligation to support those who are asked to bear burdens for the public good. In the context of public health, this principle means that when individuals or communities are required to adhere to measures such as quarantines, travel restrictions, or social distancing, they should be provided with adequate support to mitigate any hardships they face.
For example, during the COVID-19 pandemic, governments implemented financial assistance programs to help those affected by lockdowns and business closures.
Proportionality
Proportionality means that public health interventions must be appropriately scaled to the level of risk or harm being addressed. For instance, during a localized outbreak of a foodborne illness, targeted recalls and closing affected restaurants might be justified, but broader restrictions on the entire food industry would be excessive.
The principle ensures that public health measures are no more intrusive than necessary, balancing the need to protect public health with respect for individual freedoms.
Transparency
Transparency involves open communication and honesty about the goals, methods, and potential impacts of public health interventions. By clearly communicating the rationale behind health policies and interventions, public health leaders can foster accountability and public buy-in.
When a city implements restrictions on public gatherings to control the spread of an infectious disease, for example, health authorities need to explain the rationale behind these measures, the evidence supporting them, and the anticipated duration. Open communication helps build trust and reduces confusion.
By addressing concerns and uncertainties upfront, transparency encourages cooperation with public health measures.
Why Public Health Ethics Matters
Public health ethics shapes the entire scope of public health practice, influencing everything from routine preventive measures to long-term health policies. When applied thoughtfully these ethical standards guide public health decisions that are not only effective but also fair and respectful.
Ethical considerations can also play a pivotal role in how health crises are addressed. A complex example of this is the handling of the HIV/AIDS epidemic.
Early in the crisis, governments and public health systems, including those in the United States, delayed action due to a combination of stigma, misinformation, and a failure to prioritize the health of marginalized groups, particularly the LGBTQIA+ community. This lack of response, paired with widespread discrimination, contributed to the loss of countless lives that could have been saved if ethical public health principles — such as justice and beneficence — had been applied more consistently.
However, later interventions, such as the introduction of antiretroviral therapies and global education campaigns, successfully slowed the spread of the virus and extended the lives of millions. These actions helped rebuild trust, but the damage from earlier missteps highlights the long-term consequences of failing to act with integrity and care in public health.
The Consequences of Unethical Public Health Decisions
The devastating consequences of unethical public health decisions are well-documented, perhaps most infamously in the Tuskegee Syphilis Study. Conducted between 1932 and 1972, the study involved hundreds of Black men who were left untreated for syphilis, even after a cure — penicillin — became widely available.
The researchers knowingly withheld treatment and misled participants, causing immeasurable harm. This blatant disregard for the principle of non-maleficence permanently damaged trust in public health institutions, especially within Black American communities.
Ethical Dilemmas in Public Health
Public health professionals often face difficult ethical dilemmas. Some of the most pressing include the following:
- Balancing individual rights with collective safety: During the COVID-19 pandemic, governments imposed lockdowns and mask mandates to protect public health. However, these measures raised questions about personal freedom, autonomy, and the appropriate balance between individual rights and the needs of the wider population.
- Privacy versus public safety in disease surveillance: During disease outbreaks, governments may track personal data to monitor the spread of infections. Balancing this with individual privacy rights presents an ongoing ethical challenge.
- Cultural sensitivity in global health programs: When deploying health interventions in different communities, public health initiatives must respect local beliefs and traditions. Ethical frameworks demand that these initiatives be designed in ways that honor cultural differences without sacrificing the effectiveness of public health measures.
- Resource allocation during disasters: In situations such as earthquakes or hurricanes, decisions about where to send limited resources — such as medical teams or supplies — often require quick judgments. These decisions must consider both the immediate needs and long-term health impacts on populations.
Ethical Theories in Public Health
Ethical theories in public health can help professionals in the field consider important questions that guide them to make decisions that are both effective and ethically sound. Some of these theories include the following:
Utilitarianism
Utilitarianism emphasizes maximizing benefits for the greatest number of people. In large-scale vaccination campaigns, for example, public health officials may prioritize vaccinating the majority of a population to prevent a widespread outbreak, even if some individuals opt out.
Utilitarianism has shaped efforts such as the global push to eradicate smallpox, where mass vaccinations led to long-term benefits for entire populations.
Deontology
Deontological ethics, by contrast, focus on duty and adherence to established rules, regardless of the outcomes. Public health professionals often face situations where the protection of individual rights such as privacy or consent must be upheld even when doing so may hinder broader public health goals.
During an infectious disease outbreak, for instance, deontological ethics would argue that respecting individuals’ confidentiality remains a moral obligation, even when revealing health information could assist in tracking the spread of the disease.
Principlism
Principlism offers a flexible and comprehensive framework by combining multiple ethical principles — justice, autonomy, beneficence, and non-maleficence — to guide complex decisions. This approach recognizes that public health decisions often involve competing priorities, which require professionals to weigh several principles at once to find the most ethical path forward.
For example, in a situation where a new public health initiative conflicts with individual autonomy, principlism helps navigate the tension between the needs of the community and respect for personal freedom.
During a disease outbreak, public health professionals may encounter individuals who refuse treatment or vaccination due to their personal beliefs. Applying the principle of autonomy, officials would consider these individuals’ rights to make their own health choices, but they would also weigh the need to do good for the community.
Consequentialism
Consequentialism focuses on the outcomes of actions as the primary basis for determining their morality. In public health, consequentialist reasoning seeks to assess the impacts of interventions on population health and well-being, emphasizing the importance of achieving positive outcomes for the greatest number of people.
A common example of consequentialist thinking in public health is the decision to implement measures such as social distancing or quarantine during an infectious disease outbreak. Public health professionals may weigh the long-term benefits of preventing further transmission against short-term inconveniences or economic disruptions caused by such measures.
Ethical Frameworks in Public Health
Ethical frameworks help guide public health professionals in their efforts to improve population health and health equity. These frameworks provide a structured approach to the following:
- Making difficult decisions
- Balancing competing values
- Ensuring that public health actions are morally justified
While no single, universally agreed-upon framework for public health ethics exists, public health leaders have developed various models to assist public health practitioners in making balanced decisions. Two widely recognized ethical frameworks include the following.
The American Public Health Association Code of Ethics
The American Public Health Association’s (APHA) Public Health Code of Ethics is grounded in values such as professionalism, health justice, and inclusivity. The framework focuses on the importance of public health professionals acting with integrity, and making decisions committed to fairness and justice.
At its core, the APHA framework encourages public health professionals to prioritize vulnerable populations and address factors such as poverty, race, and education, which can have a significant impact on health outcomes.
The code emphasizes the importance of inclusivity and community engagement, advocating for public health initiatives that involve input from the populations they aim to serve. This framework helps guide professionals in making decisions that not only protect public health but also promote social justice and equity.
Childress’s Public Health Ethics Framework
Another influential ethical framework comes from bioethicist James Childress and his colleagues. It outlines five criteria for evaluating whether a public health intervention is ethically sound:
- Effectiveness: An intervention needs to be effective in achieving its goal of protecting public health. Without clear evidence that a strategy will improve health outcomes, it cannot be ethically justified.
- Proportionality: The benefits of an intervention need to outweigh any potential harms. This condition ensures that public health measures are not excessively burdensome relative to the health benefits they are expected to produce.
- Necessity: An intervention needs to be necessary, meaning that no less morally troubling alternative exists that could achieve the same results. This condition highlights the importance of exploring all available options before choosing a course of action.
- Least Infringement: Even when an intervention meets the first three conditions, efforts should be made to minimize the degree of infringement on individual rights and freedoms. This helps minimize negative consequences.
- Public Justification: Public health authorities have an ethical responsibility to provide clear, transparent justification for their actions. This condition requires open communication with the public to explain why a particular intervention is necessary and how it aligns with ethical principles.
How Global Health Professionals Can Approach Ethical Issues
The following strategies can help public health professionals successfully navigate ethical issues:
Monitoring Evolving Standards
The field of public health is constantly evolving, and so are the ethical codes and frameworks that guide practice. To make informed decisions, global health professionals need to stay updated on the latest research, best practices, and ethical guidelines from organizations such as the World Health Organization and the APHA.
By regularly engaging with the latest developments in both global health and bioethics, professionals can ensure that their decisions reflect the most current ethical standards.
Cultural Humility
Cultural humility goes beyond simply understanding cultural differences. It involves engaging in a continual process of self-awareness and mutual respect. Cultural humility encourages professionals to acknowledge that they do not have all the answers and must learn from the communities they serve.
It also requires recognizing power imbalances and challenging stereotypes, assumptions, and biases that may impact public health interventions. In this approach, public health professionals work alongside communities, allowing local perspectives and values to guide solutions.
For instance, in addressing maternal health in different regions, understanding and respecting local traditions around childbirth — such as the role of midwives or home birthing practices — can improve trust and enhance the effectiveness of public health initiatives. Practicing cultural humility means staying open to learning and adapting interventions that honor the unique values, beliefs, and experiences of different populations.
Community Engagement
Prioritizing community engagement is critical to ensure that interventions align with the values and needs of those they serve. Involving communities in public health decisions helps to foster trust, promotes transparency, and ensures that public health measures are not imposed from the top down.
For example, involving community leaders in the rollout of vaccination campaigns can help address concerns and increase acceptance. Ethical decision-making is strengthened when those affected have a voice in the process.
Career Paths for Public Health Professionals
Ethical leadership plays a critical role in shaping global health policies, particularly during health crises where decisions can have profound effects on populations. As public health challenges grow in complexity and scale, the demand for professionals who can lead ethical decision-making processes will increase.
Public health ethics has many career paths for professionals who are committed to navigating the complex moral challenges in global health. Individuals interested in specializing in this area can pursue roles such as the following:
Public Health Ethics Officer
Public health ethics officers ensure that public health policies, programs, and interventions adhere to ethical standards. They offer guidance on issues such as resource allocation, public health equity, and protecting individual rights during health initiatives.
The role requires a comprehensive understanding of public health ethical frameworks and the ability to apply them to situations such as pandemic response, vaccination policies, and health disparities, all while balancing the needs of the community with individual freedoms.
Public Health Policy Advisor
Public health policy advisors work closely with government agencies, nonprofit organizations, and global health leadership to develop and advocate for policies that prioritize ethical considerations. They play a crucial role in advising on policies that impact population health, such as vaccination mandates, resource allocation, and public health crisis response.
Advisors need to weigh public health benefits against individual rights and ensure that policies reflect both ethical principles and community needs.
Global Health Consultant
Global health consultants advise governments, international organizations, and NGOs on ethical approaches to health challenges worldwide. Whether working on issues such as access to healthcare, global pandemics, or health disparities, these global health professionals ensure that ethical principles guide interventions and strategies.
Their work often involves navigating the intersection of health equity, cultural values, and international human rights.
Prioritize Ethics to Build Public Health Solutions
From the frameworks that help shape policies to real-world applications in crisis management and resource allocation, public health ethics provides the foundation for creating more effective public health solutions.
For aspiring global health professionals, it’s crucial to prioritize ethical principles so that every decision serves the greater good while respecting individual rights.
Find out how Tulane University’s Doctor of Public Health (DrPH) in Leadership, Advocacy, and Equity prepares public health leaders to navigate complex ethical questions and make their mark on the future.
Recommended Readings
Effective Leadership in Public Health: Essential Skills
Importance of Data Collection in Public Health
Public Health Workforce Training and Development: Tips for Leaders
Sources:
American Public Health Association, “Public Health Code of Ethics”
Centers for Disease Control and Prevention, About The Untreated Syphilis Study at Tuskegee
Centers for Disease Control and Prevention, Public Health Ethics
The Journal of Law, Medicine and Ethics, “Public Health Ethics: Mapping the Terrain”
The New England Journal of Medicine, “Closing the Public Health Ethics Gap”
World Health Organization, “WHO Code of Ethics”
World Health Organization, “Data Show Marked Increase in Annual Cholera Deaths”