Why is preventive medicine exempted from ethical constraints?

Should public health respect autonomy?

This paper suggests that public health, due to its community orientation, may be ignoring certain ethical principles--namely the rights of individuals and communities to self-determination. The expectation of individual rights as a member of a community is reviewed and the additional right of a community for self-determination is proposed. The influences on ethical evaluations by the legal and economic environments are suggested, using US examples. The conclusion argues that as the focus of health-care delivery changes, it will become more important to consider these questions of group ethics.

Medical ethics and the public health

The development of preventive medicine is reviewed from an historical perspective. In its third and current stage of development preventive medicine has become involved in the life cycle of individual diseases and this presents a number of ethical difficulties for doctors and not least those concerned with the public health. Some proposed responses are considered and rejected. It is concluded that participants should be given more detailed information about screening tests and that doctors are under an ethical obligation to consider with the utmost care any contra-indications to a particular vaccination or a screening procedure in an individual patient. Serious reservations are expressed about the ethics and scientific justification of some government preventive medicine programmes currently in operation or projected.

Issues in preparing ethical guidelines for epidemiological studies

The Nuremberg Code of 1947 is often taken to mark the beginning of the modern age of ethical codes for medical and health-related research with human subjects. The 1947 Code was fashioned in response to inhumane medical experimentation revealed at the Nuremberg War Crimes Tribunal. The fact that, prior to 1939, Germany had an ethical code for human research in medicine that appears sensitive and sophisticated even by current standards indicates that codes in themselves do not assure ethical conduct. Nevertheless, calls continue for the preparation of codes of conduct to guide the exercise of ethical judgment in health-related research.

Medical research concerned with individual subjects as such now possesses codes or guidelines at many levels, including funding agency, research institutional, national and international levels. The World Medical Association's Helsinki Code is now in its fourth version, and the Guidelines proposed in 1982 by the World Health Organization affiliate, the Council for International Organizations of Medical Sciences (CIOMS) is about to be revised to take account of a decade of significant developments.