PoPulationand Public HealtH etHics

policy
essential to examine the history of biomedical ethics over the decades since
the Nuremberg Code was formulated in 1947.
The principles of autonomy and individual choice, as well as that of consent,
have historically prevailed in 20th century bioethics frames, particularly in
the Western developed countries. 6 This narrow framing of biomedical ethics
around individual choice and protection of research subjects has overlooked
ethics in developing or less affluent countries. It also neglected ethical issues
in a context of populations. Moreover, this approach does not recognize that
public health extends beyond the immediate treatment of individual patients
to include crucial infrastructures in many forms and shapes: medical and
health outcomes databases; population biobanks; education of medical staff
and doctors; local, regional and international standards on technologies;
standards on international development aid; and aid effectiveness in developing
countries. 5,7,8
Indeed, the ethical concern over individual choice, autonomy and consent
should be understood as being embedded within such broader health infrastructures
that together constitute public health and public health ethics.
Such public health infrastructures are not distributable goods, 4,5 nor do they
represent targeted health interventions (e.g., unlike prescription medication)
that can be subject to individual choice and consent. Public health infrastructures
sustain, and are sustained by, the global or regional populations and
thus raise entirely different sets of ethical issues that relate to collective action.
9,10 Collective action refers to organization of individuals’, institutions’
or governments’ goals, values and priorities to permit sufficient cooperation
among them and by extension collective human agency towards common,
shared and explicated targets. 9,10 The ethical issues raised by collective action
such as free-riders, unlike those addressed by traditional biomedical ethics,
are governed by principles such as solidarity and citizenship. 6,11,12
This case study describes malaria as endemic to, and vastly affecting public
health in, tropical nations, nations that are often low- and middle-income
countries (lMICs). A broad range of ethical issues seriously affecting 21st
century population health in lMICs are raised in this case, issues that cannot
be adequately identified or resolved successfully within the individual
choice- and autonomy-based protectionist ethics frames inherited from the
20th century ethics discourse.
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