PUBLIC HEALTH
CODE OF ETHICS
ISSUE BRIEF
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
practitioners
1
throughout the eld. 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 Health
2
. At that time, it was already recognized that the eld of public health was experiencing dynamic
growth and that the code would best serve the eld if it were occasionally reexamined and possibly revised. Now,
as the eld 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 scientic
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 fullling ethical
obligations requires careful reection and intentional decision making. Public health is an evidence-informed
practice. Public health actions are based on scientic 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 denes the
shared foundational values of public health. These values form the high-level moral justication 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 identied by the Public Health Accreditation
Board (PHAB)
3
. These domains do not exhaust the full range of the eld 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 eld 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 conicting values and ethical dilemmas when they arise,
Section 1: Introduction Public Health Code of Ethics 1
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 specic 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 conict with one’s personal interests and even obligations. Fullling 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 difcult 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 ofce or authority for personal gain. Codes are documents in which such special
professional obligations are pledged and explained.
When reecting on ethics, many rst 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 eld 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.
Section 1: Introduction Public Health Code of Ethics 2
Identifying and cultivating ethical best practices is a reective 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
conict with one another, and examines the practical implications these values hold for policy and the benecial
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 “ourishing” or well-being, which has a broader, more
inclusive connotation. With the appropriate support, many live ourishing lives with impairments or illness. As
used here, ourishing 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
specic vulnerabilities at the extremes of age. The term human ourishing also underscores the relational
interdependence among human beings, which is expressed in virtually all social and cultural activity and ts well
with the contemporary understanding of the social determinants of health. The preconditions of everyone’s health
are communal and systemic, and the eld of public health must address them as such. Human ourishing 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 ourishing is not only disease or ill health but also domination, inequity, discrimination,
exploitation, exclusion, suffering, and despair: in a word, the stultication 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 inuences 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 rst 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 eld. Debate and discussion of the provisions of an ethics code can prompt and set in motion a
Section 1: Introduction Public Health Code of Ethics 3
healthy process of institutional self-reection and sensitization.
Empirical and philosophical research in public health ethics has increased signicantly in recent years and has
become an important area of scholarship. It will continue to examine specic areas of public health policy and
practice, and ways should be found to bring the ndings 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
eld 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 eld falling short of its own ideals and those of the broader society.
Section 1: Introduction Public Health Code of Ethics 4
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 denitions. They
require ongoing and explicit reection and reafrmation.
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, scientic, 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 scientic 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 inuenced by secondary interests. Public health decision
makers need to be transparent and honest about disclosing conicting interests and inuences.
B. Health and Safety. Health and safety are essential conditions for human ourishing. 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 ourishing 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
inuence to promote equitable distribution of burdens, benets, 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 difcult 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 ourishing of humans, communities, nonhuman animals, and the ecologies in which
they live. Attention to potential intergenerational conicts over resources can sometimes be essential.
E. Human Rights and Civil Liberties. While coercive legal measures limiting behavior can be ethically justied
in certain circumstances, overall the effective and ethical practice of public health depends upon social
Section 2: Public Health Core Values and Related Obligations Public Health Code of Ethics 5
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
ourishing 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 2: Public Health Core Values and Related Obligations Public Health Code of Ethics 6
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 conict, resulting in the need to nd common ground and
seek integrity-sustaining compromise. Resolving ethical tensions does not mean nding 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
Identication 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 ts 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 justication for the proposed public health
action or program can best be publicly justied 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 conicts 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 signicant decisions concerning such
interventions and policies are made. If these issues are not considered, whatever the ultimate decision, it would be
difcult to say that the decision had been given sufcient ethical scrutiny.
Permissibility: “Would the action being considered be ethically wrong even if it were to have a good
outcome?” Ethics seeks to dene 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 sufcient. 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 benecially 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,
Section 3: Guidance for Ethical Analysis Public Health Code of Ethics 7
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 difcult 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 nonprot sector.)
Respect: “Would the proposed action be demeaning or disrespectful to individuals and communities even if
it beneted their health?” Respect supports human dignity within transactions, exchanges, and relationships.
These considerations remain relevant even when—indeed, especially when—there is a signicant 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 reect 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 ofcials 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
Section 3: Guidance for Ethical Analysis Public Health Code of Ethics 8
effective success is not ethically justied. 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 difcult 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 benets
and costs, particularly those for which difcult 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 benets
they bring and the costs they impose, provided that those benets 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 signicant benet 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 justiably 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 signicance.
Accountability and Transparency: “Would the proposed action withstand close ethical scrutiny and be
justied 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 difculty and seriousness of purpose involved in public health decision making,
even if they disagree with the specic decision or outcome in question. Real-time transparency, especially in
Section 3: Guidance for Ethical Analysis Public Health Code of Ethics 9
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
reective 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 justication 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, reection, and co-learning to promote dialogue that identies the ethical,
psychological, social, cultural, and economic impacts and difcult trade-offs of decisions. Public deliberations
are also oriented toward nding 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 3: Guidance for Ethical Analysis Public Health Code of Ethics 10
SECTION 4. ETHICAL ACTION GUIDANCE FOR POLICY AND PRACTICE IN FUNCTIONAL
DOMAINS OF PUBLIC HEALTH
Previous sections of the code have identied 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 specic 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
scientic 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 specic conditions and factors that impinge on particular policies and
decisions. This denition and interpretation of ethical action recommendations is generally in keeping
with the use of the term “guidance” familiar in the eld of public health and applicable to many kinds of
considerations, not only to ethics.
Specic ethics guidance in a eld as functionally diverse as public health could be organized in many
ways. This code has adopted a classication 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 classication 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 specic 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.
Section 4: Ethical Action Guidance for Policy and
Practice in Functional Domains of Public Health Public Health Code of Ethics 11
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 decits (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 dene 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 decits 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-dened 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
Section 4: Ethical Action Guidance for Policy and
Practice in Functional Domains of Public Health Public Health Code of Ethics 12
a 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
conicting points of view. Public health must remain in dialogue with the communities it serves.
4.1.4. Prioritize health problems and disseminate relevant ndings. Once community health problems
have been identied 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 condentiality. In small communities and when small numbers
are involved, inadvertent personal identication is a possibility and steps should be taken to safeguard
against it. Similarly, certain terminology and classication 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 reexivity to minimize the inuence of biases on the research process. Public health
practitioners should engage in ongoing reexivity and acknowledgment of their positionality in the
context of sociocultural and political inuences. Engaging in practices that help characterize those
biases and their inuence on professional actions and interactions is especially important. Critical self-
reection 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 ndings. Ongoing reexivity 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
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involved in any investigation. General issues such as maintaining condentiality to the extent possible and avoiding
conicts 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 condentiality 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 efciently. 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 notiable 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 conicts of interest that could interfere with the willingness to acknowledge public
health threats. Personal or organizational conicts of interest and conicts of commitment (e.g.,
subordinating the obligation to public service to more parochial interests or objectives) must be
avoided, as they could inuence how a public health practitioner or public health agency acknowledges
or responds to a threat. Organizational conicts 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 efciently 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 efciently
and effectively.
4.2.4. Ensure data validity, account for the limitations of available data, determine statistical
thresholds for dening signicance, 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 identies 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 modiers in analyses, conclusions, and reports; and protect against
misinterpretation, misrepresentation, and misunderstanding of data and ndings. This applies to data
from both quantitative and qualitative research.
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4.2.5. Give special attention to protecting the privacy and condentiality 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 condentiality. 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 specic populations or create nancial 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 ndings 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 specic areas or accessible to specic
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
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meaningful opportunities for dialogue; being open to unanticipated ideas; attuning themselves to
cultural, social, and historical contexts that inuence 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 insufcient) 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 eld. 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.
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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 scientic 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, co-
learning, 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, efcacy, 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.
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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 decits 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, reecting deeply situated knowledge of where and how people
connect, share ideas, and inuence positive change.
4.4.7. Be attuned to cultural, social, and historical contexts that inuence 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 reected 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 condential 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
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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, efcacy, 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 scientic 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. Specically designed intergenerational conversation may allow
richer conversation bridging past, present, and future.
4.5.2. Incorporate scientically vetted, research-based data to the fullest extent possible. Valuable
nancial 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.
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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 specic 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
identiable 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 specic population audiences.
4.5.9. Ensure that reasonable alternative options are considered and evaluated and that nal 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 specic 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.
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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 benets
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, specic 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 specic
needs, beliefs, and preferences. These factors should be incorporated to the greatest extent possible to
facilitate a sense of inclusion while simultaneously enhancing the efcacy 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 fulll 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 ofcials 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 efciently
to produce just outcomes, with a fair and equitable distribution of resources.
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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 specic 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 nal 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 fulll 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 scientic 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 nance 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.
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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 nancial 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 modication 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 insufcient. 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
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citizenship status. Citizenship status can be irrelevant to fullling 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 ofcials 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 eld 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 signicance 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 nancial 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 elds and should not be deterred—or forced to
make undue personal or family sacrice—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.
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4.8.4. Provide adequate institutional and professional support to enable competent performance.
In public health, as in other elds, 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 signicance 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. Scientic
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 specic 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
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vigilance in staying responsive to ever-changing community and organizational needs and excellence
in programmatic response. Moreover, it relates to other critical aspects of scientic 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 specic CQI projects, omitting relevant stakeholders accidently 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 specied 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 nd 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 nancial 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 benet 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
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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 ourishing.
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 eld 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 ndings from multiple disciplines as well as the lived experience of affected communities. In
addition, it requires evaluation of the strength and appropriateness of various ndings 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 delity and responsibility, effectiveness,
inclusivity, and responsible use of limited public resources.
4.10.2. Emphasize that scientic 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 conicting ndings. Evaluation of evidence requires an understanding of
the relative merits of various research methods, scientic disciplines, and types of data available given
the specic public health problem being addressed. Using the strongest and most appropriate evidence
available helps public health practitioners and organizations achieve their obligations of delity 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.
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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 delity, 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 qualied public
health practitioners in managerial roles. The managerial capability of an organization depends
upon the quality, experience, and professional expertise of those who ll 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 ofces 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 nancial disclosures and prohibitions on conicts of interest, including
perceived conicts of interest applicable to all directors, management, staff, and the
organization itself. The misuse of ofce or position for personal nancial gain or other types of unfair
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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 conicts 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 beneciaries
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 reected 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. Quantiable 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 justication of government policies, regulations, and activities; and to inuence the development and
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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 efciently 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 efciency 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.
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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.
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