Clinical practice is characterized by a personal physician-patient relationship [1]. Conversely, public health practice is characterized by global attention to whole populations and therefore by an emphasis on collective health conditions, prevention, and social, economic, and demographic determinants of health and disease [2]. The collective perspective is described effectively by the Institute of Medicine (IOM) in its well-known report, “The Future of Public Health,” in which public health is defined as “what we, as a society, do collectively to assure the conditions for people to be healthy” [3].

The historical relationship between clinical ethics and public health ethics is the subject of debate: differing and sometimes contradicting opinions regarding both the historical development of public health ethics and its main cultural models can be found throughout the literature.

Some authors suggest that public health ethics, in addition to its slower and more recent historical development, is actually in conflict with clinical ethics: “in contrast to the traditional emphasis of bioethicists on the physician-patient relationship, public-health ethics focuses on the design and implementation of measures to monitor and improve the health of populations. In addition, public-health ethics looks beyond health care to consider the structural conditions that promote or inhibit the development of healthy societies” [4]. Most of the authors ascribe this difference to the utilitarian nature of public health. For example, Bayer and Fairchild attribute the origins of this discrepancy to the eminently utilitarian approach of public health, which is aimed at maximizing collective well-being even to the detriment of individual care [5].

On the contrary, Wynia and other authors believe that public health ethics is neither slow [6] nor opposed [7] to clinical ethics and that new “bridges between medical care and public health” should be built [8].

There are also middle positions. For example, Dozon and Fassin have studied the historical development of public health with “an anthropological approach”: even though the authors do not explore the historical development of public health ethics in great depth, they highlight the cultural development of public health and include “morality” in this discussion [9].

In this sometimes debated area, it is highly significant to note the absence of chapters devoted specifically to public health ethics in the majority of books on the history of bioethics and medical ethics [10–16]. Similarly, books discussing the theoretical basis of bioethics usually have not discussed the foundations of public health ethics until recent years. This characteristic seems to be present in books from various cultural and linguistic contexts, including English [17], French [18], and Italian [19].

On the other hand, the historical perspective on the ethics of public health is not disregarded in public health texts [20,21]. This situation is meaningful: it indicates that while bioethics has not paid much attention to public health ethics for many years, public health professionals themselves perceive a real need for it.

Regardless of potentially different interpretations of its historical development, interest in public health ethics is undoubtedly growing on at least three levels: operational [22], deontological [23], and theoretical [24]. In other words, if there was actually a delay in the emergence of public ethics with respect to clinical ethics during the early years in which bioethics began to become consolidated as an autonomous field of study during the seventies and eighties, then during the nineties that gap was closed. This evolution has been pointed out by Kass, who published a historical analysis of public health ethics in 2004, subdividing it into two main periods: “The early era: 1970s−1990s” and “Stage II: the emergency of frameworks, the language of public health ethics” [25].

Since the nineties, the increasing importance of ethical issues in the debates about public health policies has become evident in different cultural contexts. Examples in francophone countries include the Ethics and Public Health (Éthique et santé publique) Conference that took place in Nantes on March 13–14, 1997 [26] and the National Public Health Priorities (Priorités nationales de santé publique) Conference that took place in Montréal on November 18–19, 1997 [27]. Many aspects of public health ethics have been extensively developed in anglophone countries. Among others, one example is the ethics of infectious diseases [28]: Dawson and Verweij have provided important contributions to this field [29].

Public health ethics is not only in need of theoretical models, but also of practical frameworks. Unlike the duties of clinicians to patients in clinical medicine, professional standards for ethical practice are not well defined in public health. As Taboada and Cuddenback observe, “incorporating ethical analysis into public health raises many challenging questions. For example, what does ethical analysis add to public health beyond legal or public policy analysis? Is the law itself subject to a process of ongoing ethical scrutiny? When ethicists appeal to ‘values,’ who gets to decide which values are worthy of protection or how these values should be prioritized in cases of conflict? How should ethical analysis address the tension between universal principles and culturally specific values, and find common ground among individuals from diverse cultural backgrounds? Such questions have practical implications for how public health policies are designed, implemented, and evaluated” [63].

In 2001 Kass published “an analytic tool, designed to help health professionals consider the ethics implications of proposed interventions, policy proposals, research initiatives and programs” [64]. The tool is based on six main questions: (1) “what are the public health goals of the proposed program?”; (2) “how effective is the program in achieving its stated goals?”; (3) “what are the known or potential burdens of the program?”; (4) “can burdens be minimized . . . [and] are there alternative approaches?”; (5) “is the program implemented fairly?”; and (6) “how can the benefits and burdens of the program be fairly balanced?”.

In 2002, Childress and colleagues suggested some “general moral considerations” for an ethical framework in public health ethics: producing benefits; avoiding, preventing, and removing harms; producing the maximal balance of benefits over harms and other costs (often called utility); distributing benefits and burdens fairly (distributive justice); ensuring public participation, including the participation of affected parties (procedural justice); respecting autonomous choices and actions, including liberty of action; protecting privacy and confidentiality; keeping promises and commitments; disclosing information as well as speaking truthfully (often grouped under transparency); and building and maintaining trust [65].

In 2006, Nieburg, Bernheim Gaare and Bonnie proposed a “Guide to considering the ethical issues in public health practice.” The “guide” is composed of a list of questions subdivided in four main areas: “Assessing public health practice,” “Identifying and recognizing ethical issues and considerations,” “Identifying options and making and implementing public health decisions,” and “Later: evaluating the resolution(s)” [66].

In 2007, Baum and co-authors observed that “public health practitioners may lack the experience, time, resources (including training), or even motivation to deliberately consider ethics in their daily wok . . . However, we believe that greater clarification of the ethical underpinnings of their decisions can add value to public health works for several reasons. First, ethical clarification ensures that officials and practitioners unmask normative assumptions and explicitly, rather than implicitly, analyze values during their assessments . . . Second, ethical clarification helps balance economic analysis . . . Third, clarifying the ethical considerations integrated into a particular policy or program decision can help to illuminate decision-makers’ conceptions of the appropriate scope of public health practice.” On this basis, they suggested a framework composed of six steps: (1) “determine population-level utility of the proposed action,” (2) “demonstrate evidence of need and effectiveness of actions,” (3) “establish fairness of goals and proposed implementation strategies,” (4) “demonstrate accountability,” (5) “assess expected efficiencies and costs associated with the proposed action,” and (6) “consider political feasibility and community acceptance” [67].

Two examples that seem particularly exhaustive are described here in greater detail than those mentioned above: the Public Health Code of Ethics, by the Public Health Leadership Society (PHLS) and the American Public Health Association (APHA), and the EuroPHEN project.

In 2002, the PHLS proposed the Public Health Code of Ethics consisting of 12 principles [68]. The Code is accompanied by guidelines [69], and has also been adopted by the APHA [70]. Principle 1 identifies the primary goal of public health, which is to address “the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.” This aim is strengthened by principle 5, which refers to “policies and programs that protect and promote health”. In principle 2, the PHLS emphasizes the need for public health policies and community interests to respect the “rights of individuals in the community.” The PHLS recommends that communities be informed about public health policies (principle 6), and information is considered a requirement for effective and timely (principle 7) involvement of community members in the development of health policies (principle 3). Fairness, justice, equity are other basic principles in public health ethics (principle 4). Moreover, public health decisions should be based on scientifically sound information (principle 5), which is also the basis for timely intervention (principle 7) and improvement of the physical and social environment (principle 9). Other ethical requirements include transparency (principle 12), professional competence (principle 11), and personal data protection (principle 10). The PHLS also gives special attention to “diverse values, beliefs, and cultures in the community”: respect for them is a duty (principle 8).

According to the PHLS and the APHA, the following values and beliefs are crucial assumptions inherent to the public health perspective underlying the 12 principles of ethical public health practice:

“Humans have a right to the resources necessary for health”

From 2003 to 2006, the European Public Health Ethics Network (EuroPHEN) carried out a project entitled “Public policies, law and bioethics: A framework for producing public health policy across the European Union.” EuroPHEN’s aim was to develop a framework for producing common approaches to public health policy across Europe. EuroPHEN compared the organization of public health structures and public policy responses to selected public health problems in member states to examine how public policy in different countries weighs competing claims of private and public interest [71]. In the analysis performed within EuroPHEN, several requirements for a public health ethical framework were highlighted. First of all, it is important to be aware that a community is not a homogenous whole and to recognize that there are different cultures and disenfranchised members within the community. Next, it must be recalled that

“Public health institutions should respect the confidentiality of information that can bring harm to an individual or community if made public.”

These frameworks can be applied in multiple ways. They can be used to assess areas of ethical tensions in practice and to provide ways in which to deliberate. The frameworks are conceived to be sufficient flexible for use in practice and to balance several competing considerations rather than setting priorities among principles. Rather than emphasizing a particular ethical principle to guide decision-making, they suggest possible processes by which decisions could be reached and evaluated.

Three main kinds of questions can be raised in every ethical analysis: descriptive, theoretical, and normative. Descriptive ethics seeks to answer the question “what is right and good?”. It examines how ethics is actually expressed and put into practice. Theoretical ethics seek to answer the question “how do we justify our judgments about the right and the good?”. It is therefore concerned with justifications. Since theoretical ethics discusses what is good and what makes decisions good, its focus is on philosophical—not empirical—questions. Normative ethics focuses mainly on the arguments for how we ought to choose the good and act rightly.

The various schools of ethics (Section 2) tend to emphasize one question over the others, but all three questions are involved to some extent in any ethical theory [72]. Some of the ethical models are very different and irreconcilable, whereas certain aspects present conflicts that are not so definitive. For example, Childress and Bernheim Gaare suggest moving “beyond the liberal and communitarian impasse” [73].

According to the author of this contribution, personalism is the best approach to face ethical problems not only in clinical bioethics, but also in public health ethics [74]. Personalism, which suggests building up the common good on the basis of attention to and care for the good of each person, is the best way to solve conflicts between individual interests and social interests [75]. However, as stated earlier, the aim of this contribution is not to maintain the superiority of one model over the others, but to provide an overview of the models proposed in the literature.

In this light, Raymond Massé suggested a model that can be mentioned as a conclusion. The author identifies a list of widely shared “lighthouse values” [76], including respect for life, beneficence, the common good, responsibility, justice, solidarity, nonmaleficence, autonomy, privacy, utility, and precaution [77]. The author also suggests these principles as a basis for public health legislation [78].