Hurst, Borisch, and Mauron,1 writing on how much evidence is needed to support public health policy raise important issues for all in public health, concluding many questions that are ‘not issues of scientific fact, but issues of right and wrong’. To the discussion on evidence and values in health policy, I add the issue of ‘right versus right’ dilemmas in public health practice and consider its relevance to Public Health Associations (PHAs).

The great success of evidence to test effectiveness in of medical care drives enthusiasm for ‘evidence-based policy’. But public health interventions, unlike those in clinical medicine, need social change. Their effectiveness results from a mix of factors including leadership, changing environments, organizational history, and culture.2 It is rarely possible to test proposed public health actions in a controlled and measurable way. In public health, evidence – the ideas and definition – are complex, as Hurst, Borisch, and Mauron describe.1 Perhaps our definition of evidence should be widened:

The term ‘evidence’ has traditionally implied scientific evidence or research-based evidence, suggesting that scientific methods alone should be used to obtain the data. The WHO Regional Office for Europe believes that, although this position may be adequate within clinical practice, it is untenable in the field of public health. Moreover, it could be politically dangerous to ignore judgement, experience and opinion.3

For evidence, its collection and analysis, values become a consideration. The distinction between ‘facts and values are difficult to keep in mind in public health debates’.1 In clinical medicine, patient values have been defined as ‘the unique preferences, concerns and expectations each patient brings to a clinical encounter’.4 In public health, the values of WHO might be a useful guide. The Health for All policy Framework Update,5 is ‘values-based and values-driven’. Equity, the core value of ‘Health for All’, means that WHO gives priority to poor, vulnerable, and socially marginalized groups; solidarity, refers to a society's sense of collective responsibility; and participation implies active participation of both individuals and organizations.

Social justice, public health's core value is its ‘unique philosophy’,6 Mackie suggested7 a value-base for global public health would use two values to characterize intentions and actions to underpin socially a just public health practice: equality, fairness for individuals, communities, and populations, plus mutuality, health held in common by individuals, communities, and populations.

Recall WFPHA's Istanbul Declaration from the 12th World Congress on Public Health that called for commitment to health of populations: ‘Now is the time for all those who affect the lives of others … to assert and practice the basic human values of solidarity, sustainability, morality, justice, equity, fairness, and tolerance’.

Let's consider our philosophy, our approach to ‘evidence’, and our central values, if we are to achieve sustainable progress in health promotion. Attention to public health ethics can make a valuable contribution.

In practice, what sort of ethical issues arise? Two recent studies addressed the question.8, 9 In Scotland, Rogers identified three main categories of ethical issues: paternalism, in community consultation and when withholding information to avoid causing fear and anxiety; responsibilities, where responsibilities to stakeholders differ; and ethical decision making, where participant values conflicted with decisions based on evidence.

In Michigan, USA, Baum et al identified five broad categories: appropriate use of public health authority; decisions about resource allocation; political interference in public health practice; standards of quality of care; and the role or scope of public health.

In Scotland, very few of the participants could recall ethics education as part of their public health training. In Michigan, public health practitioners relied on consultations with colleagues to resolve challenges; infrequent use was made of frameworks for decision making, whereas in Scotland at least one health authority has laid down principles for ethical decision making.

Public health ethics have evolved so rapidly, that already public health ethical issues may evince new foci in both Scotland and Michigan.

I call attention to the ethical problems of who gets what; allocating limited resources; and deciding between valid competing interests – not right versus wrong but right versus right dilemmas. The UK's prison services in England and Scotland sought a resolution.10 The Institute for Global Ethics UK Trust (IGE UK) organized small group, 1-day seminars led by an experienced IGE trainer. They explored values and ethical decision-making using dilemmas suggested by the participants. They followed the IGE's framework – starting with moral awareness, then values definition, ethical analysis, and dilemma resolution.11

An evaluation12 concluded that the seminars addressed an ethical thinking and ethical dilemma resolution training gap found in all disciplines. Duncan suggested this approach for training public health practitioners, as it adds ethical awareness and confidence in ethical decision making.

What can PHAs learn? PHAs can make two outstanding contributions to global health improvement.

  • Awareness: PHAs can collect and transmit the voices of the people to make all aware of what is required. As WHO Director General Margaret Chan, stressed in her keynote address to the May 2011 World Health Assembly, there is a constant need to listen to the people. Debates and discussions of health policymakers have meaning only when they improve the health of people.

  • Advocacy: With awareness and knowledge, PHAs can provide informed pressure on decision makers to optimize health care and promotion in their communities, based on an understanding of the values important to the population. They can assure that those values are shared by political and professional groups who can contribute to promoting health and well-being of local communities.

PHAs can make a strong case for civil society's highly influential role in global public health development. They can consider evidence for public health policies; promote understanding of the role of values in decisions; encourage added ethical analysis training in public health; and remind all that public health's unique philosophy is social justice.