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LETTER |
Correspondence: Requests for reprints should be sent to Sofia Gruskin, JD, MIA, International Health and Human Rights Program, François-Xavier Bagnoud Center for Health and Human Rights, 651 Huntington Ave, Boston, MA 02115 (e-mail: sgruskin{at}hsph.harvard.edu).
Kass's piece "An Ethics Framework for Public Health" is welcome for its call to determine an approach to negotiating the benefits and burdens of public health policies and programs.1 All the more reason, then, to consider the ways in which the approach Kass advocates is complementary to, different from, and derivative of related work in the field of health and human rights by Jonathan Mann and others since the mid-1990s.
Kass and Mann both take as their starting point the Institute of Medicine's definition of the mission of public health—to ensure conditions in which people can be healthy—and both identify the limitations of the bioethics framework in addressing these concerns of public health.2,3 Both also recognize the central role of government in determining and providing public health interventions. Yet in the framework delineated by Kass, attention to government appears relevant only as it focuses attention on individual liberties and concerns about their infringement.
By contrast, the health and human rights frameworks elaborated by Mann and others recognize that government action ought to be compliant with the structures and procedures of international human rights law. From a health and human rights perspective, the dual obligation of governments to promote and protect both public health and human rights means that human rights not only support the creation of an ethical framework but are binding legal obligations that therefore suggest an approach to designing, implementing, and evaluating public health policies and programs.
Kass is acquainted with some scholarly work connecting issues of public health and human rights, but she errs in her interpretation. She cites the work of Gostin and Lazzarini without recognizing how their book draws on Mann's work and that they do not—contrary to Kass's claim—propose a framework for public health and human rights. Instead, as is true also of several other commentators, they draw on human rights to begin to articulate a framework for public health.4
In fact, it is in considering the example of government infringement on individual liberties in the name of public health that the differences and complementarity between Kass's approach and the health and human rights framework become evident. Kass identifies 3 broad categories of burdens that may occur as a result of public health measures and raises some of the issues to be considered in balancing the benefits and burdens imposed by a public health program. While Kass does not propose a method for this negotiation process, the international legal framework as it pertains to a government's legitimate ability to restrict rights, including in relation to public health, might offer initial guidance.5
Recognition of the relevance of international law and human rights to public health led Mann and others to propose a 4-step impact assessment to bring these concerns together.6 Kass's 6-part analytic tool appears to elaborate on this 4-step approach, but without recognition of the conceptual and operational importance of human rights that was delineated in the earlier work and that has been further elaborated since that time.7,8 I appreciate that some of the richness in the elaboration of Kass's 6-part analytic tool is new and may help inform some of the tool's uses. However, it is essential that the kind of approach Kass proposes maintain its mooring in the critical thinking and legal grounding of governmental responsibility and accountability that exist through the application of the human rights framework to this work.
References
1.
Kass NE. An ethics framework for public health. Am J Public Health.2001;91:1776–1782.
2. Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1998.
3. Mann J. Medicine and public health, ethics and human rights. Hastings Center Rep.1997;27(3):6–13.
4. Gostin L, Lazzarini Z. Human Rights and Public Health in the AIDS Pandemic. New York, NY: Oxford University Press; 1997.
5. The Siracusa Principles on the Limitation and Derogation Provisions in the International Covenant on Civil and Political Rights. New York, NY: United Nations Economic and Social Council; 1985. UN Doc E/CN.4/1985/4, annex.
6. AIDS, Health and Human Rights: An Explanatory Manual. Geneva, Switzerland: International Federation of Red Cross and Red Crescent Societies and François-Xavier Bagnoud Center for Health and Human Rights; 1995.
7. Gruskin S, Tarantola D. Health and human rights. In: Detels R, Beaglehole R, eds. Oxford Textbook on Public Health. Oxford, England: Oxford University Press. In press.
8. Gruskin S, Tarantola D. HIV/AIDS, health and human rights. In: Lamptey P, Gayle H, Mane P, eds. HIV/AIDS Prevention and Care Programs in Resource-Constrained Settings: A Handbook for the Design and Management of Programs. Arlington, Va: Family Health International. 2001:661–678.
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