During the past 20 years there has been a dramatic increase in societal interest in preventing disability and death in the United States by changing individual behaviors linked to the risk of contracting chronic diseases. This renewed interest in health promotion and disease prevention has not been without its critics. Some critics have accused proponents of life-style interventions of promoting a victim-blaming ideology by neglecting the importance of social influences on health and disease. This article proposes an ecological model for health promotion which focuses attention on both individual and social environmental factors as targets for health promotion interventions. It addresses the importance of interventions directed at changing interpersonal, organizational, community, and public policy, factors which support and maintain unhealthy behaviors. The model assumes that appropriate changes in the social environment will produce changes in individuals, and that the support of individuals in the population is essential for implementing environmental changes.

An Ecological Perspective on Health Promotion Programs

Recently, there has been a growing interest in public health and public health ethics. Much of this interest has been tied to efforts to draw up national and international plans to deal with a global pandemic. It is common for these plans to state the importance of drawing upon a well-developed ethics framework and we argue that this framework should reflect the values and insights of feminist relational theory. More specifically, we argue that pandemic planning must be squarely situated in the larger realm of public health and that an ethics framework for public health will be one that recognizes the need to pay particular attention to the vulnerability of subpopulations lacking in social and economic power. We propose an ethics framework for public health that builds on the notions of relational personhood (including relational autonomy and social justice) and relational solidarity. In this way, we aim for a public health ethics that, as appropriate, promotes the public interest and the common good.

A Relational Account of Public Health Ethics

The mandate to ensure and protect the health of the public is an inherently moral one. It carries with it an obligation to care for the well-being of communities, and it implies the possession of an element of power to carry out that mandate. The need to exercise power to ensure the health of populations and, at the same time, to avoid abuses of such power are at the crux of public health ethics.

Until recently, the ethical nature of public health has been implicitly assumed rather than explicitly stated. Increasingly, however, society is demanding explicit attention to ethics. This demand arises from technological advances that create new possibilities and, with them, new ethical dilemmas; new challenges to health, such as the advent of HIV; and abuses of power, such as the Tuskegee study of syphilis.

Medical institutions have been more explicit about the ethical elements of their practice than have public health institutions. However, the concerns of public health are not fully consonant with those of medicine. Thus, we cannot simply translate the principles of medical ethics to public health. In contrast to medicine, public health is concerned more with populations than with individuals, and more with prevention than with cure. The need to articulate a distinct ethic for public health has been noted by a number of public health professionals and ethicists.1–5

A code of ethics for public health can clarify the distinctive elements of public health and the ethical principles that follow from or respond to those elements. It can make clear to populations and communities the ideals of the public health institutions that serve them, ideals for which the institutions can be held accountable.

A code of ethics for public health

Standard bioethics textbooks present the field to students and non-experts as a form of "applied ethics." This ahistoric and rationalistic presentation is similar to that used in philosophy of science textbooks until three decades ago. Thomas Kuhn famously critiqued this self-conception of the philosophy of science, persuading the field that it would become deeper, richer, and more philosophical, if it integrated the history of science, especially the history of scientific change, into its self-conception. This essay urges a similar reconceptualization for bioethics, arguing that the analysis of moral change ought to be integral to bioethics (and to ethics generally). It proceeds by suggesting the sterility of the ahistoric, rationalist applied ethics model of bioethics embraced by standard bioethics textbooks. It also suggests the fecundity of alternative conceptions of the bioethics that focus on the history of successful and failed attempts to negotiate moral change, and the history of multifaceted relations between moral philosophy and practical ethics.

Bioethics and History

This paper sketches an account of public health ethics drawing upon established scholarship in feminist ethics. Health inequities are one of the central problems in public health ethics; a feminist approach leads us to examine not only the connections between gender, disadvantage, and health, but also the distribution of power in the processes of public health, from policy making through to programme delivery. The complexity of public health demands investigation using multiple perspectives and an attention to detail that is capable of identifying the health issues that are important to women, and investigating ways to address these issues. Finally, a feminist account of public health ethics embraces rather than avoids the inescapable political dimensions of public health.

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Feminism and public health ethics

The political focus in the United States has been on individualism with minimal restrictions on property and personal conduct. Government regulation or paternalism has been accepted, however, in the area of public health. Political thought has embraced the concepts of common or group interests which must be protected and which legitimize the police power of the state. Contemporary public health problems such as fluoridation, alcoholism, the wearing of motorcycle helmets, and the discouragement of smoking are discussed in terms of constitutional rights and the collective good. Language: en

Community: The Neglected Tradition of Public Health

Legal moralism restricts liberty as a defense against a moral rather than a physical harm. It uses law to protect the majoritys morality from the deviant group. The most potent challenge to legal moralism is its frequent collision with a more widely shared value--public health. Restrictions on liberty to promote the public health--paternalism--are today more widely accepted than legal moralism. Success in the battle against AIDS depends on replacing old images of the tightly bound community based on sodomy statutes with a more complex public health policy that combines the right to be different with the view that in matters of the common health and safety we are 1 body with a common good. A sound public health policy depends on both loosening and tightening the bonds of community. Rejecting moralism does not mean that society can have nothing to say about sexual practices. Sex per se and that includes homosexual sex is not the business of the community. But sexual practices that threaten the common health are. Modern public health rests on a complex equality that replaces traditional restrictions with limits rooted in protection against actual harms. Equating the public health with simplistic restrictions on homosexuality per se will only result in fruitless debates over matters like quarantine and isolation public health strategies that have little role in this epidemic. Hoping for a technological shortcut in the form of a vaccine is not realistic and can cost tens of thousands of lives especially if this hope keeps us from facing the task of public education and reform of our laws against homosexuality. These reforms can help prepare the way for altering sexual lifestyles among the gay community. The public health community should take the lead and state by state demand the repeal of harmful statutes and restrictions on gay life. The health of the body politic depends on rejecting the communal disease of sexual prejudice.

Morality and the health of the body politic.

How best shall we serve

\n Four disparate proposals for hospital programs, varying in their funding requirements and revenue-generating capacity, have been made to the chief executive officer (CEO) of a metropolitan nonprofit general hospital that has always prided itself on being responsive to community needs. Although the hospital faces severe financial pressures, the CEO has determined that one of the proposals can be supported. Three commentaries on this case discuss what ethical criteria should be considered in evaluating the four proposals, and what role the hospital ethics committee should play in the decision.\n

Dan E. Beauchamp

Papers

Community: The Neglected Tradition of Public Health

Morality and the health of the body politic.

How best shall we serve

How best shall we serve? Case study.

The World We Are Losing