Over $1.4
trillion, or 14 percent of its gross domestic product (GDP), was spent on
health care in the United States in 2001.   This includes billions in
transfer payments through Medicare and Medicaid programs.  Certainly
health care is a major priority in the U.S. and elsewhere, and the parameters
and operationalization of health policies affect more people, more directly,
than any other industry.

Health care policy
is not so much articulated or legislated, though, as it is molded and formed by
the dynamics and dialectics of various stimuli (changing cultural expectations,
scientific and technological advances, etc.) and limitations (budgetary,
ethical, political, individual choice, etc.). Public
Health Law and Ethics: A Reader captures the discursive components
of those tensions and processes: government reports, scholarly articles, and
court cases that address the ethical, legal, and political issues in the theory
and practice of public health.  This work, compiled and edited by
Georgetown University law professor Lawrence O. Gostin, is a sequel and
companion text to his 2000 publication, Public
Health:  Power, Duty, Restraint.

This Reader generally
consists of three major parts (ethical, legal, and social), plus an epilogue
that addresses the future of public health.  The ethics section includes,
along with a few legal cases, of a collection of scholarly articles and opinion
pieces, organized around four perspectives:  population-based views of
public health; communitarian approaches, human rights analyses, and
rationalistic (including cost/benefit) perspectives.  If there is a common
theme, it is the underlying presumption that improvements to the health of the
largest majority of people ought to drive, or at least inform, health-related
policy decisions.  These essays are not monolithic (Gostin includes a delightful
excerpt from a 1850 report by the Sanitary Commission of Massachusetts, wherein
the writer questions whether squalid and disease-ridden conditions may be
allowed on private property as a matter of property rights), but they do tend
to revolve around utilitarian norms and communal ways of thinking about ethics.

The law section,
as might be expected, is largely comprised of court opinions issued by state
and federal appellate and supreme courts, along with excerpts from a few law
journal articles.  The court opinion illustrate the judiciaries’ rationale
as they sort out and rule on the standards of care applicable to public health
agencies and professional health caregivers, as well as the corresponding
duties and reasonable expectations of patients.  A few special topics,
such as the use of junk science in the courtroom, are also included.

Many ethics issues
— such as the striking of a proper balance between public health research and
recordkeeping, on the one hand, and privacy rights on the other — cannot be
resolved without resorting to political theory.  Gostin highlights these
types of issues in a separate section of his Reader that addresses
society-versus-the-individual concerns that arise in connection with
public health education, immunization, screening, quarantines, health-related
crimes, and the like.  And he includes similar issues, such as
bioterrorism and genetic intervention, as part of his closing, future-oriented
chapter of this work.

Public
health-related policies are involved and reflected in public finance, in
legislation, in litigation, in regulation and deregulation, and in governmental
efforts to persuade people to change their private behavior. Public health can
also be understood in narrow terms (patient by patient, decision by decision),
or in broad terms (responding to an urge to attempt the optimization of
society’s health).  The latter view is articulated by the Institute of
Medicine’s definition: "Public health is what we, as a society, do
collectively to assure the conditions for people to be healthy." 
Gostin’s Reader captures, but does not resolve, the tensions between
these views.

Some readers might
expect this type of anthology to address specific value-related ethical
matters, such as public health policies regarding therapeutic abortions,
infanticide, euthanasia, cloning, and the use of human embryos (and stem cells)
in medical research.  Gostin offers no discussion of these issues. 
Similarly, alternative methods of financing health care (medical savings
accounts, flexible spending accounts, health reimbursement arrangements, etc.)
are not addressed. Instead, Public Health Law and Ethics:  A Reader
offers the reader a manageable mainstream of public policy considerations,
without approaching the more theological, or at least ideological,
morality-related aspects of public health care discourse.

Graduate students
(including those studying ethics, law, and medicine), for whom this Reader
appears to have been primarily intended, will discover within it a helpfully comprehensive
explanation of most of the dynamics that inform today’s public health debates.
Gostin’s own introductions to the text, and to each chapter, reflect a high
level of familiarity, and scholarly adeptness, with these issues.  The
text’s supplemental website at http://www.publichealthlaw.net/reader
provides updates to the cases in included in the Reader (and additional,
more recent rulings) as well as other information. Health care professionals and
administrators, lawyers who are new to health care law, and political
scientists, will also find this Reader to be an effective tool in
gaining access to what can be an overwhelming body of legal and bioethical
knowledge.
 
  

© 2002 Albert D. Spalding
 

Albert D. Spalding, JD, is an associate professor at Wayne State University School of Business
Administration.  He teaches legal studies topics, including a course
in Health Care Law and Ethics.

Categories: Ethics