Historical, Legal,

and Ethical
Perspectives on
Public Health Policy
Previous session overview
▪Health Policy - Set course of action undertaken by
governments or health care organizations to obtain a desired
health outcome
▪Health Policy at the Local, State, and Federal Levels
▪Health Policy Development
▪scope of health policies
▪Health Policy Analysis – Retrospective and perspective
▪Health Policy - Regulation and Health Policy Connection
▪Policy triangle – context, content, process
▪The stages of health policy analysis –
▪High Opposition, Medium Opposition, Low opposition,
neutral, low support, medium support, high support

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Overview
◼ Public health orientation
◼ Public health law
◼ History of public health regulation
◼ Ethical issues in public health

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SectionA

Population Basis of PublicHealth

Populations/Individuals
◼ Orientation of public health is to the health of populations
◼ Orientation of medical care is to the health of individuals

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Domain of PublicHealth
◼ What is the domain of public health?
◼ provides broad public health perspectives and skills necessary to
assume effective leadership in public health practice, reflecting
the three domains of health improvement, health protection
and health service quality.

◼ What are public health issues?

◼ Public Health Issue #1: Cardiovascular Disease
◼ Public Health Issue #2: Type 2 Diabetes
◼ Public Health Issue #3: Hypertension
◼ Public Health Issue #4: Schizoaffective Disorder
◼ Public Health Issue #5: Clinical Depression
◼ Public Health Issue #6: Borderline Personality Disorders

https://online.maryville.edu/blog/12-common-public-health-issues/

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Population BasedPerspective
◼ “Public health is oriented toward the analysis of the
determinants of health and disease on the population basis,
while medicine is oriented toward individual patients.”
− Elizabeth Fee

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Population BasedPerspective
◼ “Public health services are those shared by all members of the
community, organized and supported by, and for the benefit
of, the people as awhole.”
− Larry Gostin

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Population BasedPerspective
◼ “Public health is what we, as a society, do collectively to
assure the conditions for people to be healthy.”
− IOM

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BlurryLinesbetweenPublicHealthandMedicalCarefor
CertainIssues

◼ Health insurance coverage

◼ Health care spending
◼ Health care policy

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OneoftheCriterionintheEightStepModelIsOftenLegality

◼ Is the proposed changelegal?

◼ What is the legal basis for public health?

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Tradeoffs inPublic Health Law
◼ Improved health vs. autonomy, privacy, and other individual
rights
− Which takes priority?

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SectionB

Public Health Law

Public HealthLaw-Definition
◼ “Public health law is the study of the legal powers and
duties of the state to assure the conditions for people to be
healthy (e.g., to identify, prevent, and ameliorate risks to
health in the population) and the limitations on the power
of the state to constrain the autonomy, privacy, liberty,
proprietary, or other legally protected interests of
individuals for the protection or promotion of community
health.”
− Gostin, “A Theory and Definition of Public Health Law,”
p. 4

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FiveComponents of Public HealthLaw
1. Role of government
2. Power to assurecompliance
3. Public concerns
4. Direct service provision
5. Relationship between governmentand public

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Roleof Government inPublic Health
◼ Governments play a major role in health care financing
by mobilizing the necessary resources through
public budgets and other contributive mechanisms,
pooling resources allocated to health development,
guiding the process of resource allocation and
purchasing health services from various providers.

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Government Public HealthRegulation—Historical
Perspective

◼ 1700-2006—gradual increase in government’s role in public

health
◼ Continual debate over when the public welfare is more
important than individualrights
◼ Continual debate over improved health or individual
freedoms
− Improved health graduallywinning

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Government Public Health Regulation—1700s and1800s
◼ Travel at sea
◼ Quarantines
◼ Inoculations
◼ Food inspections
◼ Garbage control

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AdditionalRoles—1900s
◼ Sanitary movement
− Response to epidemics
◼ Surveys of health conditions
◼ Regulation of food, sewage, water, etc.

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Additional Roles—Early 20thCentury
◼ State boards of health
◼ Bacteriology
◼ Disease reporting
◼ Food and drug administration

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Additional Roles—Late 20thCentury
◼ Greater regulation ofprivate sector
◼ National Institutes of Health established
◼ Air and water quality standards (EPA)
◼ Limited tobacco advertising
◼ Communicable disease reporting
◼ Pesticide production
◼ Consumer product safety
◼ Occupational health and safety

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GovernmentHealthRegulationinthe21stCentury
◼ What additional public health roles will be needed?
◼ Which of these items are highest priority?

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SectionC

Legal Issues in PublicHealth

WhatAretheLegalIssuesinPublicHealth?
◼ When should government act to promote community health?
◼ When should government protect individual freedoms?

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Are these the CoreFunctions ofPublic Health?
◼ Prevent epidemics
◼ Protect against environmental hazards
◼ Promote healthy behaviors
◼ Respond to disasters
◼ Assure quality of healthservices

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ArethesetheEssentialFunctionsofPublicHealth?
◼ Monitor community healthstatus
◼ Investigate health problems
◼ Educate the publicabout health
◼ Enforce health and safetyprotections
◼ Fund research
◼ Assure competent workforce

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Ethics and PublicPolicy
◼ Laws and regulations can be influenced by ethical concerns
◼ Ethical concerns can influence policydebates

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Moral Constraints versusPublicPolicy
◼ How do moral constraints differ from the criteria used to
evaluate public policies?

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Ethics
◼ The term used to describe various ways of examining the
moral life
◼ The systematic study of morality
− Beauchamp and Childress (2001)

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Moralit
y
◼ Morality is the term used to describe those set of beliefs
concerning right and wrong human conduct which are so
widely shared as to form a stable consensus
− Common morality—norms that bind all persons in all
− places
Community-specific moralities—norms which are
binding upon members of particular religions, cultures, or
professions
€ Beauchamp and Childress (2001)

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Moral Goals of PublicHealth
◼ Producing benefits
◼ Avoiding/minimizing harms
◼ Maximizing benefits overharms

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General MoralConsiderations
◼ We consider two general types of moral considerations in
public health
− Those that relate directly to the goals of public health
− More general considerations whichserve as constraints
on what we can do to achieve the goals of public health
€ Childress, et al.(2002)

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ResourceAllocation
◼ Policy is about resourceallocation
◼ Opportunity costs
− Alternative ways toallocate resources

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Principles of DistributiveJustice
◼ Strict Egalitarianism
− Every person should have exactly the same level of
material goods or services
◼ Utilitarianism
− Resources distributed in a way that maximizes the welfare
of all thepeople
◼ Dessert-Based Principle
− Resources distributed to those people who deserve
certain benefits or rights in light of their actions
(contribution, effort, or need for compensation)
◼ Difference Principle
− Resources to be distributed in a way that the least-
advantaged people receive the maximum possible gain

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Question
◼ What should be the principle for allocating public health
services?

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Individual Rights vs. CollectiveGood
◼ Smoking
◼ Drinking
◼ Toxic waste
◼ Ergonomics
◼ Seat belts
◼ Gun ownership

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MoralDilemmas
◼ Moral Dilemmas exists when . ..
− There are good moral arguments which dictate that one
do action “X” AND there are good moral arguments which
dictate that one NOT do action “X” BUTarguments on
either side do not clearly outweigh the others
− There are good moral arguments which require that one
do action “X” AND good moral arguments which require
that one do action “Y” BUT circumstances are such that
you cannot do both AND the arguments for one do not
clearly outweigh the arguments for the other
€ Beauchamp and Childress (2001)

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Moral Dilemmas versusPolicyDebates
◼ What are the similarities?
◼ What are the differences?

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AGeneral Strategy for Public HealthEthics Analysis
◼ Identify the ethicalproblem
◼ Assess the available facts relevant to the problem
◼ Identify stakeholders
◼ Identify the values atstake
◼ Identify the availableoptions
◼ Consider the process and values pertaining to process

NotesAvailable 39
SectionD

Application: Medicare Modernization Act of 2003

Exampleof Political/LegalIssue
◼ Medicare Modernization Act of2003
− Also known as the Prescription Drug Bill
− Designed to give health and prescription drug benefits to
Medicare recipients in 2006

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Medicare Modernization Act of2003: Background
◼ Medicare passed in 1965 without prescription drug coverage
◼ Private sector and Medicaid have drug coverage
◼ Strong push by elderly for drug coverage

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Situation in2003
◼ Medicare going broke
◼ Republicans believe fundamental reformis necessary
◼ Limited ($400 billion over 10 years) amount of money is
available

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LegislationPasses
◼ Minor reforms toMedicare program
◼ Substantial payments to hospitals, managed care plans, and
rural providers
◼ Prescription drug coverage with significant gaps in coverage
and no controls over pharmaceutical spending

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1. Define the Problem—PoliticalDebate
◼ Republicans need todefend legislation
◼ Democrats need tocriticize legislation

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Define theProblem—Policy
◼ High drug prices needed to support pharmaceutical research
and development
◼ Drug benefits insufficient

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2. AssembleSomeEvidence
◼ How much more does the U.S. pay for prescription drugs?
◼ Do gaps in coveragemake a difference?

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 Relative PricesofPharmaceuticals
◼ Relative prices of 30 pharmaceuticals in 4 countries (2003)
20% US
Discount

1.2

1.00
1.0

0.8
Price Index

0.66
0.60
0.6 0.52

0.4

0.2

0.0
United States Canada France United Kingdom
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Medicare Spending onDrugs
◼ Spending on Medicare prescription drug benefits in 2006

Total drug
Out- Third-
spending Medicare
of- party
(billions)
pocket payers

A. Current
legislatio 101.9 44.5 31.0 26.4
n

B.Alternative
benefit 73.6 44.5 19.1 9.9

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Current and Alternative Out-of-PocketMedicare Costs

Reduction in out-of-pocket costs under current

and alternative Medicare drug benefits, by number
of chronicconditions
$1,200
Mean reduction in o-o-p

$1,000 CurrentLegislation
Alternative Benefit
$800
spending

$600
C
$400

$200

$0
0 1 2 3 4 ormore

Number of chronicconditions

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3. Construct theAlternatives
◼ Do nothing
◼ Price controls
◼ Discount cards
◼ Reimportation

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4. Select theCriterion
◼ Political contributions
− AARP
− Pharma
◼ Votes of seniors
◼ Access to existingpharmaceuticals
◼ New drug development

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5. Project theOutcomes

Do Nothing Price Controls Discount Cards Reimportation

AARP –– ? + +

Pharma ++ –– + –

Votes of seniors –– ? ? ++
Access to
pharmaceutical
0 ++ + +
s
Drug
developmen
++ –– 0 –
t

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6. Confront theTrade-offs
◼ Which constituency is more important—AARP or Pharma?
◼ Which concern (access or research and development) is most
important?

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7.Decide

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8. Tell YourStory
◼ Access to pharmaceuticals ◼ New medicines/new hope
for Medicare beneficiaries

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