Sofia Gruskin is with the Program on International Health and Human Rights and the Department of Population and International Health, School of Public Health, Harvard University, Boston, Mass. Bernard Dickens is with the Faculty of Law, University of Toronto, Toronto, Ontario.
Find articles by Sofia GruskinSofia Gruskin is with the Program on International Health and Human Rights and the Department of Population and International Health, School of Public Health, Harvard University, Boston, Mass. Bernard Dickens is with the Faculty of Law, University of Toronto, Toronto, Ontario.
Find articles by Bernard DickensSofia Gruskin is with the Program on International Health and Human Rights and the Department of Population and International Health, School of Public Health, Harvard University, Boston, Mass. Bernard Dickens is with the Faculty of Law, University of Toronto, Toronto, Ontario.
Requests for reprints should be sent to Sofia Gruskin, JD, MIA, Harvard School of Public Health, 665 Huntington Ave, 1-1202, Boston, MA 021115 (e-mail: ude.dravrah.hpsh@niksurgs).
Accepted August 7, 2006. Copyright © American Journal of Public Health 2006Dedication of this issue of the Journal to the theme of “Rights and Ethics” complements this month’s Annual Meeting and Exposition of the American Public Health Association, titled “Public Health and Human Rights,” and highlights the congruence of inclusion of both human rights norms and ethical standards in public health work. Historically, the promotion and protection of human rights as embodied in the United Nations Universal Declaration of Human Rights1 draws upon human rights principles, including those on the health and well-being of populations, to which many nations were already committed. Similarly, ethical conduct in health care can be traced in spirit to the time of Hippocrates and has its modern expression in the area of bioethics. Although there are key differences enabling each to be applied separately to public health efforts, human rights and health care ethics support and compliment each other when applied together in efforts to improve public health.
Traditionally, human rights norms are meant to guide the actions of governments, whereas ethics in health care much more broadly encompass concern for the specific actions, inspirations, and relationships of individual health workers, researchers, and organizations. The ethical principles that guide our work are the product of broad-based consultation, are drafted by representatives of professional bodies and organizations, and exist in the form of guidelines and proposed codes of conduct. For example, the World Medical Association adopted the Helsinki Code in 1964.2 The Helsinki Code, which initially focused on research involving human subjects, was the precursor to the field of bioethics, which encompasses research in life sciences as well as the ethics of health practice. In the United States, bioethics, as developed in the late 1960s and early 1970s, emphasized the central priority of individual autonomy, reflecting the individualism of American culture, in contrast to the social solidarity characteristic of many other cultures. A key feature of ethical guidelines, as recently evidenced with stem cell research and HIV vaccines, is that they can be rapidly adjusted or drafted to meet evolving scientific and human challenges, allowing for regional or national variation as needed.
By contrast, human rights norms and standards tend to be drafted by government representatives, negotiated in political forums, and incorporated in the body of international law in the form of international treaties that impose legal obligations on the governments that ratify them. Although these processes allow human rights law a permanency and legitimacy useful for engaging governments and institutions of power, there is less flexibility and less rapid adaptation possible than with ethical guidelines. The 1948 Universal Declaration of Human Rights, although significantly shaped through the diplomatic skills of American Eleanor Roosevelt, reflects the principles of many cultures and traditions and the consensus achieved among governments of what rights should exist. The international legal conventions that came after the declaration bind the governments of the countries that sign on to them, and in so doing affect what is and should be done to protect health.
The public origins of, and accountability for observance of, human rights highlights the value of human rights to public health concerns.3 For instance, the International Covenant on Economic, Social, and Cultural Rights4 recognizes in article 12 “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health” and establishes associated governmental responsibilities. These responsibilities include reducing infant mortality; improving environmental and industrial health; preventing, treating, and controlling epidemic, endemic, occupational, and other diseases; and ensuring the availability of medical care in the event of sickness. Article 21 of the International Covenant on Civil and Political Rights5 protects freedom of peaceful assembly even as it accepts restrictions necessary for “the protection of public health.” Other rights relevant to the health and well-being of populations include access to such goods and services as information, food, clothing, housing, and safe workplaces, as well as environmental rights to clean water and air. An evolving notion of a right to development, constituted from these and other rights, requires governmental initiatives for protection of public health interests relevant to the environment and for promoting the economic development that generates resources for individual and public health and for environmental protection and enhancement.
In a world in which hunger, poverty, and environmental degradation are all too evident, it would be unrealistic to demand governmental remedies on the basis of their international human rights commitments alone, but these commitments provide a useful framework for shaping national laws and policies, provide a useful tool for ensuring accountability, and point to approaches useful for promoting public health. There is much that governments should and can do.
A 5-point agenda outlines how the health sector can promote population health.6 The first agenda item is to institutionalize the systemic and routine application of human rights perspectives to all health sector actions. In many, if not all, societies, the poor or marginalized benefit too little from public health initiatives. Ongoing efforts are required to reduce social inequalities in health, including in the receipt of health care, health service financing, and allocation of health care resources. These efforts should include adequate health infrastructure and personnel, in particular where poverty levels are highest, and policies or practices to eliminate gender, racial/ethnic, and other forms of discrimination, as they may affect access to and use of services.
The second goal of this agenda is to strengthen and extend public health functions to create the basic conditions necessary to achieve health and well-being. Health sector contributions to these efforts include establishing programs for clean water and sanitation, food and drug safety, tobacco control, and health education and disseminating information about and setting standards for safe workplaces, housing, transportation, and environmental conditions. Effective action in these areas requires collaboration with sectors of government not accustomed to working in health-related fields. An added benefit of human rights law is that it clarifies the obligations of all sectors of government to promote and protect human rights and, in doing so, provides support to the health sector for working with new partners.
Equitable financing of health care is the third point in the rights-based agenda for public health. Principles of proportionality to achieve the human rights goal of “the highest attainable standard of physical and mental health” require that individuals with the least resources pay the least, both in absolute terms and as a proportion of their total resources. This requirement also means that a lack of personal resources should not prevent an individual from receiving services that are recommended on the basis of prevailing norms and scientific knowledge. Meeting this requirement is, however, a particular challenge for societies with a heavy disease burden, competing health and social priorities, and constrained resources.
The fourth point mandates action to ensure that health care services can be provided effectively in response to the major causes of preventable health conditions, particularly among the poor and disadvantaged. Health institutions, however financed, will need to make systematic and sustained efforts to develop infrastructure to provide equitable services. These efforts include identifying and reducing the obstacles that keep disadvantaged groups from receiving the full benefits of health initiatives—obstacles such as discrimination on the basis of language, race/ethnicity, gender, and sexual orientation. As a first priority, control of largely preventable conditions should be emphasized, such as maternal mortality and morbidity, HIV/AIDS, and tuberculosis. Despite pressure from financial donors for immediate results, health institutions must have public health strategies that focus on the long term and that address the underlying and common root causes of disease, including poverty, discrimination, and neglect of human rights.
The fifth agenda point is to monitor, advocate, and take action to confront the human rights implications of development policies in all sectors that affect health. Drawing on the World Health Organization’s description of health as a state of “physical, mental and social well-being,”7 (p2) this point of the agenda would support the health sector in monitoring those public and private sector actions that affect health (beyond those actions with obvious medical connections) and would include broad health and development concerns. There are no clear natural limits to the scope of public health concerns or to the application of human rights principles to ameliorate the public’s health, recognition of which can allow for increasing efforts to achieve progress in human rights and public health.
Ethics also provides a basis for a broad spectrum of actions and may complement the actions originating from human rights perspectives, even though its guidelines for and influence on health care are more a product of philosophical reflection, health professional and health organization perceptions, academic analysts’ commentaries, and, contributions from special interest groups, for instance those concerned with specific disorders. Although a number of guidelines and codes of conduct exist, of particular interest to public health workers will be the revision and reformatting of the International Guidelines for Ethical Review of Epidemiological Studies,8 produced in 1991 by the Council for International Organizations of Medical Societies (CIOMS). Rather than produce a separate document for public health research, CIOMS has developed a draft9 to appear as a supplement to the 2002 CIOMS International Ethical Guidelines for Biomedical Research Involving Human Subjects.
The CIOMS draft supplement focuses on the distinct aspects and challenges of epidemiology and is concerned primarily with those studies focusing on personally identifiable health records for which the consent of individuals cannot be feasibly asked or given, those using surplus or archived biological samples, and those that might bring about group disadvantage and stigmatization. Application of these guidelines to public health research may highlight unresolved questions about the contrasts between public health research and practice and the value of imposing a more medical model on social science investigators. It is hoped, however, that use of these guidelines will widen the vision of health care ethics beyond medical sciences to social sciences so that health systems research, qualitative studies, and population-based studies will be embraced and public health studies within the mainstream of ethical concerns in health care will be generated.
Human rights and ethics in health care are closely linked, both conceptually and operationally. Each provides unique, valuable, and concrete guidance for the actions of national and international organizations focused on health and development. One can appreciate the distinct values of human rights and ethical principles and the differences in the paradigms each represents. Public health professionals can contribute to the application of each, and find value in each, but may do so in different ways and through different means of observance, action, and enforcement.
1. Universal Declaration of Human Rights. United Nations General Assembly Resolution 217 A (III). New York, NY: United Nations; 1948. Available at: http://www.un.org/Overview/rights.html. Accessed September 6, 2006.
2. World Medical Association Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects. Helsinki, Finland: World Medical Association; 1964. Available at: http://www.wma.net/e/policy/b3.htm. Accessed September 7, 2006.
3. Gruskin S, Tarantola D. Health and human rights. In: Detels R, McEwen J, Beaglehole R, Tanaka H, eds. Oxford Textbook of Public Health. 4th ed. New York, NY: Oxford University Press; 2002:311–335.
4. International Covenant on Economic, Social and Cultural Rights. New York, NY: United Nations; 1966. UN document A/6316. Available at: http://www.unhchr.ch/html/menu3/b/a_cescr.htm. Accessed September 7, 2006.
5. International Covenant on Civil and Political Rights. New York, NY: United Nations; 1996. UN document A/6316. Available at: http://www.ohchr.org/english/law/ccpr.htm. Accessed September 7, 2006.
6. Braveman P, Gruskin S. Poverty, equity, human rights and health. Bull World Health Organ . 2003; 81 : 539–545. [PMC free article] [PubMed] [Google Scholar]
7. Constitution of the World Health Organization. Available at: http://www.searo.who.int/aboutsearo/pdf/const.pdf. Accessed September 7, 2006.
8. Council for International Organizations of Medical Sciences. 1991 international guidelines for ethical review of epidemiological studies. Available at: http://www.cioms.ch/frame_1991_texts_of_guidelines.htm. Accessed September 7, 2006.
9. Council for International Organizations of Medical Sciences. Special ethical considerations for epidemiological research. Available at: http://www.cioms.ch/special_ethical_consideration.pdf. Accessed September 7, 2006.
Articles from American Journal of Public Health are provided here courtesy of American Public Health Association