To the Betterment of Public Health

This article was originally published by the American Journal of Ethics. Citation: Virtual Mentor. 2003;5(11):359-360.

Physicians' ethical obligation to the health of the public is clearly laid out in the Principles of Medical Ethics. Principle VII states: "a physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health."

Physicians have the opportunity to contribute to the betterment of public health more often than they may know. This issue of Virtual Mentor focuses on how physicians' every day clinical decisions affect the health of the public. We present clinical encounters in which physicians are faced with situations of public health concern such as patients who are being abused or struggling to tell partners about their HIV-positive status. We examine how physicians' other ethical obligations, such as keeping patient-physician confidentiality, may conflict with their interests in protecting the public and with legal mandates. Physician choices, such as opting to practice concierge medicine or not considering cost-effectiveness in treatment decisions, may also affect public health by making health care less accessible and affordable. We offer a perspective on physician roles in curbing patient decisions that are not in the best interest of society such as refusing to have children vaccinated.

The learning objectives for this issue on public health ethics are:

• Understand how patient confidentiality may be compromised by public health reporting laws.

• Identify circumstances in which physician autonomy may conflict with public health interests and goals.

• Understand how individual medical decisions in the aggregate are public health decisions.

• Recognize how health care spending on individuals uses finite nonrenewable resources and may impact the health of the public.

We encourage physicians to think about the important role they have in public health policies and initiatives. Whether or not they are formally trained in the public health field, all physicians are protectors of the health of the public.

In this role physicians must act as advocates for patients who are abused and work to improve health literacy. They must maintain high standards of patient care and also think about cost-effective medical practice. Physicians must educate patients about lifestyle choices and other preventive medicine measures before their health deteriorates, which means discussing a reasonable postpartum weight-loss program with a patient who is in her third trimester of pregnancy; talking to a recently divorced, middle-aged patient about healthy stress relief and a low-salt diet before his blood pressure skyrockets. It means recounting the dangers of smoking and the monetary savings of quitting to smoker-patients rather than just checking the box marked, "Smoker, Yes" and insisting that elderly patients get flu vaccines.

It means standing on your soapbox of healthy living with all your patients and recognizing that decisions physicians and patients make during individual clinical encounters add up to public health decisions.