In this section we outline major approaches to ethical analysis. Three approaches have shaped ethical reasoning in general, medical ethics and Public Health ethics. Ethical traditions have been shaped mainly by the deontological, consequentialist and virtue based approaches [11–13]. Such traditions or paradigms have been extensively considered for the field of medical or clinical practice, but only comparatively recently have the significant differences and challenges within public health (with its collectivist focus on safeguarding the community and promoting well-being) been appreciated [14].
For Public Health ethics it is important first to come to some agreement of what is meant by public health. How it is defined and what is its content–mission, functions, and services? Definitions for health and for Public Health vary widely [15]. Health can be defined inter alia as absence of diseases, as well-being [16], or as the means to (or resources for, or foundations of) achieving goals [17]. Herewith, the point of Public Health is to protect and improve the health of populations and to engage social justice. Related to this focus on groups are the following definitions of public Health: “Public Health is what we, as a society, do collectively to assure the conditions of people to be healthy” [18] and “Public Health involves not only traditional government actions to protect the public from imminent danger, but also, at a more fundamental level, cooperative behavior and relationships of trust in communities, as well as a far reaching agenda to address complex social, behavioral and environmental conditions that affect health” [18].
In contrast to some other sciences more focused on creating new knowledge, Public Health practitioners know what they are hoping to achieve: the improvement in population health not in health of individuals [5, 19]. By public health ethics we mean understanding how to evaluate different courses of action and non-action and their individual and social consequences. As such, public health ethics embraces the range of methods used to analyze, interpret and evaluate the variety of ways individuals and groups interact with each other in a framework of ethics. Herewith, ethics refers to the way of evaluating, reflecting, understanding and criticizing what constitutes moral life and actions and manifests itself in reflections and case studies in Public Health [11]. Herewith development of modules in teaching public health ethics build on students’ knowledge to experience ethical modules as something they do, not as something done to them.
Generally, ethical reasoning seeks to provide an account of how humans assign and evaluate the rightness or wrongness of arguments and their consequences. Additionally, ethics is related to interpersonal duties and obligations that are not regulated or compelled by external authority. As indicated above, in the past (and sometimes still today) ethical reasoning in public health has been approached as a sub-set of medical ethics [14, 20–22].
Following this application of ethical reasoning, it is necessary to distinguish between applied ethics and ethical theories in public health. Descriptive ethics relates to accounts of how humans behave, normative ethics considers what should be done. Both approaches have a long tradition in medical ethics.
Medical ethics in health care has a long tradition, and has focused on the dyadic clinical relationships between medical doctors and patients and a set of issues related to such relationships (e.g. autonomy, beneficence, non-maleficence, justice, consent, confidentiality [13]. The most common environment for such reasoning is the hospital where patients seek medical care. In those situations, the patient is in a vulnerable state, seeking relief from a problem. The clinician is in a role of authority which is based largely on their knowledge and their resources. Such, there is thus an imbalance of power between the patient and the clinician. This imbalance includes power imbalance in terms both of knowledge and power to act. The key principles of medical ethics are therefore related to such situation: regulating the potential abuses of power between clinicians and patients; between one who holds most of the authority and resources, and the other who is vulnerable in part because of his or her illness. Because of the orientation towards relationships in medical ethics, the concepts of autonomy and the’ negative rights’ of the person (e.g. the right not to be harmed) have tended to dominate in this field of medical ethics [23].
Taken together, traditional medical ethics has an occupation with distributive justice at the micro-level, to the neglect of broader social and global justice issues. In contrast, public health presents and creates distinctive ethical challenges, not just problems already familiar from medical ethics because it is embedded by definition in a population perspective [21, 24–26]. As a consequence of the population perspective, public health sometimes promises benefits for population groups at the cost of benefits for individuals [24]. This may create tension between the rights and individuals and the rights and needs of populations [27].
Additionally, in contrast to clinical medicine which uses medical interventions to cure or treat existing illness, public health uses primarily non-medical means such as infrastructure improvement, policy, law and behavioral health to prevent illness. This aspect means that Public health ethics needs a broader framework to analyze competing interests.