PoPulationand Public HealtH etHics

groups would likely be more effective. The utilitarian model thus often overlaps
significantly with the need-based model, avoiding ineffective waste of
resources, but it may also abandon some of the people in greatest need if it
is too difficult or resource-intensive to help them. The utilitarian model is
the most likely of the three to emphasize the comparative costs of various
prevention and intervention strategies, as the other two emphasize values of
equality and beneficence respectively, rather than efficiency.
Social justice: The vicious circle of socio-economic disparity, increased
health risk, compounded stigma and resulting reinforcement of socio-economic
exclusion is well illustrated in the HPV example. As noted in the
scenario, a need-based approach to HPV prevention risks (re)stigmatizing
those at greatest risk of illness; because HPV is a sexually transmitted virus,
targeted HPV prevention may also inadvertently imply sexual promiscuity or
irresponsibility among at-risk groups. Further, the groups most at risk have
often been marginalized and pathologized in previous public health efforts.
Given the clear influence of marginalization and poverty in the incidence of
cervical cancer, are we attracted to the vaccine in order to avoid undertaking
the vastly more difficult, but more ethically compelling and, ultimately,
more effective efforts to improve underlying social determinants of health?
Gender justice: Epidemiologically, women suffer the effects of HPV infection
more often, and more severely, than men. The extent to which the sexes are
considered to be responsible for those health outcomes, however, is an ethical
question deserving of reflection. Age-old double standards hold women
responsible for sexuality and reproductive outcomes: unplanned pregnancies
and infertility have long been “blamed” on women, despite the biological necessity
of both sexes in procreation. Have we succeeded in fully rooting out
these old sexist attitudes and double standards in contemporary views about
sexually transmitted infections?
Reframing the HPV vaccine as either an “anti-cancer” or “anti-stI” vaccine
may reflect subtle but important shifts in the assignment of responsibility.
Cervical cancer may be perceived as a consequence of women’s sexual behaviour;
the vaccine may be thus be perceived as a response to “irresponsible”
sexuality that increases women’s risk exposure, as opposed to a morally neutral
response to a common virus. Vaccinating both men and women to reduce
the spread of stIs would indicate that both sexes are held equally accountable
for the health of their sexual partners as well as themselves.
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