In clinical medicine, responsibility is to the individual patient. I have often thought that in public health, our responsibility is to the population–to the group, the collective, the strange amalgam of “society.” As somebody put it, “the responsibility of physicians is to the patient. Our patients are all of society.” Many go into public health from either planned or actual medical careers because of the realization that effective change begins with more than the patient. There are all sorts of theoretical and very practical problems that arise from this dichotomy–including the very definition of ethic’s ‘beneficence’–a pillar of medical ethics. In public health, there are frequently divergent views of what specific acts and changes are beneficent, and to whom. This takes us into the whole realm of social justice–distributive justice–the ‘who benefits?’ and at whose expense? And what is society? And what is the relationship between individuals and society? These are deeply social and philosophical issues.

I have been thinking about this a great deal and am embarking on a long term project on the juxtaposition of individual rights and collective rights in public health, and when and how they can conflict. Vaccination, motor cycle helmet laws, environmental tobacco smoke, the health plan now before the Supreme Court, all are examples of this. I began thinking of this a long time ago when I first got into TB research and realized the immense potential ethical conflicts of forced quarantine and even medication for somebody with MDR-TB, for example–a person not willing or able to take medication, and therefore serve as incubators for selection of further resistant organisms. So boom….

This brings me full circle to when I was finishing my clinical and policy ethics fellowship in the late 1980s–3 years, funded by Kellogg. Issues of ethics and moral action usually don’t just disappear. Over the next 2 years, I’ll be trying to tackle some of these issues, and will be writing about them here from time to time.