Public health ethics, like the field of public health it addresses, traditionally has focused more on practice and particular cases than on theory, with the result that some concepts, methods, and boundaries remain largely undefined. This paper attempts to provide a rough conceptual map of the terrain of public health ethics. We begin by briefly defining public health and identifying general features of the field that are particularly relevant for a discussion of public health ethics.Public health is primarily concerned with the health of the entire population, rather than the health of individuals. Its features include an emphasis on the promotion of health and the prevention of disease and disability; the collection and use of epidemiological data, population surveillance, and other forms of empirical quantitative assessment; a recognition of the multidimensional nature of the determinants of health; and a focus on the complex interactions of many factors—biological, behavioral, social, and environmental—in developing effective interventions.

Calls are increasing for American health care to be organized as a learning health care system, defined by the Institute of Medicine as a health care system “in which knowledge generation is so embedded into the core of the practice of medicine that it is a natural outgrowth and product of the healthcare delivery process and leads to continual improvement in care.” We applaud this conception, and in this paper, we put forward a new ethics framework for it. No such framework has previously been articulated. The goals of our framework are twofold: to support the transformation to a learning health care system and to help ensure that learning activities carried out within such a system are conducted in an ethically acceptable fashion.

Vulnerability is one of the least examined concepts in research ethics. Vulnerability was linked in the Belmont Report to questions of justice in the selection of subjects. Regulations and policy documents regarding the ethical conduct of research have focused on vulnerability in terms of limitations of the capacity to provide informed consent. Other interpretations of vulnerability have emphasized unequal power relationships between politically and economically disadvantaged groups and investigators or sponsors. So many groups are now considered to be vulnerable in the context of research, particularly international research, that the concept has lost force. In addition, classifying groups as vulnerable not only stereotypes them, but also may not reliably protect many individuals from harm. Certain individuals require ongoing protections of the kind already established in law and regulation, but attention must also be focused on characteristics of the research protocol and environment that present ethical challenges.

OBJECTIVES. Many contextual analyses that bridge the micro-level-macro-level gap in identifying risk factors for adverse outcomes have not used methods appropriate for multilevel data. The purpose of this paper is to illustrate the application of appropriate multi-level analytic methods and discuss their implications for public health. METHODS. A previously published individual-level model of physical violence perpetrated by male partners during the childbearing year was reanalyzed to include variables describing the neighborhoods where the women resided. Logistic regression with estimation methods of the generalized estimating equation was used for the contextual analysis. To assess the advantages of the generalized estimating equation over conventional logistic regression, both were used for the two-level model. RESULTS. The regression coefficients from the contextual model differed from the betas obtained in the individual-level model. Not only were neighborhood-level variables related to the risk of partner-perpetrated violence, but the presence of these macro-level variables in the models modified the relationships of the individual-level variables to the risk of violence. CONCLUSIONS. Two-level models that include individual- and community-level factors may be beneficial for purposes of explanation in public health research.

No abstract