New code serves as ethical guidance for public health: Revised code first in US since 2002
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* Mark Barna

Urban tree canopies improve quality of life and public health. They can beautify a neighborhood, raise residential property values and help reduce air pollution and sun exposure.

So it would make sense that a plan to plant trees in a disadvantaged Detroit community would be welcome by residents. But that was not the case. Hundreds of residents did not want the trees, leaving organizers at the Greening of Detroit, an environmental nonprofit contracted by the city, confused.

The pushback might have been avoided had organizers studied public health ethics before launching the tree-planting program, Selena Ortiz, PhD, MPH, an assistant professor of health policy and administration at Penn State, told *The Nation’s Health*. An updated Public Health Code of Ethics, released Nov. 4 at APHA’s 2019 Annual Meeting and Expo, is designed to support sound decisionmaking.

“I think of tree planting as a public health intervention,” said Ortiz, chair of the APHA Ethics Section, which led development of the new code.

If the Detroit organizers had access to and followed the new public health code, “it could have led to a very different outcome,” Ortiz said.

The 30-page ethics code might have guided the nonprofit to have an in-depth conversation with the community. The workers would have learned the complex history residents have had with the city and its planting of curbside trees, and how that relationship bred resident mistrust. Knowing this, the workers might have been more persuasive in getting residents on board for the green intervention.

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/49/10/1.3/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/49/10/1.3/F1)

In health and medicine, ethic codes are taken very seriously. The most famous is the Hippocratic oath, an ancient Greek codification of ethics for physicians. The spirit of the oath remains in the American Medical Association’s Code of Medical Ethics.

But medical ethics do not always overlap with what public heath workers do. Public health involves populations, not just individuals, and focuses on prevention rather than treatment or cure. Public health needs its own ethics.

“We care about individual health, but we are responsible for community health,” Lisa Lee, PhD, MA, MS, co-leader of an APHA task force that created the new code, told *The Nation’s Health.* “And sometimes, what is in the best interest of a patient from a physician’s perspective is not completely aligned with what is in the best interest of a community from the perspective of public health professionals.”

U.S. public health had no formal ethics code until 2002, when health researchers working with the Public Health Leadership Society released a set of principles in APHA’s *American Journal of Public Health.* Prior to that, public health workers followed codes established at their workplace or cobbled together from their field of specialty, such as sociology, anthropology, nursing or epidemiology.

The 2002 code was widely accepted and served public health well, but was always considered by its authors to be a living document. An update would eventually be needed to square with changing times.

Over the last two decades, greater understanding has developed involving social determinants of health, including racism and gender bias. And climate change has amplified a host of human health concerns. Addressing these issues is a major part of public health today.

Moreover, social inequity has increased since the Great Recession of 2007, creating more hardship for low-income people and minorities, Amy Fairchild, PhD, MPH, dean of the Ohio State University College of Public Health, said at an Annual Meeting session announcing the new code.

Job descriptions of public health workers have also changed, as many take positions in the private sector. The days when most new graduates joined a state or federal health agency with similar tasks and challenges are gone.

Seeing the changes, the APHA Ethics Section formed a task force in 2015 to develop a code in line with the evolving public health landscape.

The APHA Public Health Code of Ethics contains six core values and obligations for U.S. public health. The document offers guidance for ethical and fair decisionmaking in practice and on policy.**“The new code defines these values and provides guidance for how to implement strategies and guide us for ethical action, which I think is a step further than the previous code.”***— Lisa Lee*

Some issues in public health involve trade-offs. For example, limiting spread of sexually transmitted diseases means balancing individual privacy rights and stanching disease spread. Contact tracing, involving notification to someone that their sexual partner is STD positive, has proven effective in limiting infections. But it can be personally intrusive.

The APHA code is designed to get stakeholders talking about ethical trade-offs, but also practical issues on conducting a fair and moral community intervention that respects and listens to community members.

The document is not meant to impact disciplinary proceedings or sanction professional misconduct.

“It is meant to stimulate a conversation about ethics that might not otherwise have occurred,” APHA member Bruce Jennings, MA, an adjunct associate professor in the Center for Biomedical Ethics and Society at the Vanderbilt Medical Center and co-leader of the APHA ethics task force, said at the Annual Meeting.

In the case of the Detroit tree-planting program, over 1,800 out of 7,400 city residents, or 24%, in disadvantaged neighborhoods rejected the free trees between 2011 and 2014, according to a study published in January 2019 in *Society and Natural Resources.*

The Greening of Detroit had conducted an information campaign on the benefits of tree cover, but the nonprofit did not explore residents’ distrust of government. Decades earlier, it turned out, the city had cut down trees in many disadvantaged neighborhoods. Residents worried it would happen again, or that they would be saddled with the expense and labor of tree maintenance, researchers at the University of Vermont and the University of Michigan found.

“Here is an example of making sure there is public participation and discussion, and not just assuming that we are going to go into these communities and we will plant trees or do whatever intervention that maybe has been shown to be effective,” Ortiz said. “I think there are a lot of communities that feel exploited, don’t feel heard, and we have to be really, really cognizant and sensitive of that.”

The code offers recommendations, based on 12 ethical domains from the Public Health Accreditation Board. The domains drill down to articles that offer advice and explanation. They explore ethical considerations when conducting assessments on population health, investigating environmental health hazards, engaging with a community, developing policies and plans, and applying evidence-based research, among other principles.

Relevant to the Detroit intervention, the code discusses how to engage, empower and train community members in a project, and how workers can be more attuned to cultural, social and historical contexts that might impede intervention.

“If I am looking at an ethical problem, I want to have (the code) rolling around in my head,” said Lee, an APHA member and associate vice president for research and innovation at Virginia Tech. “The new code defines these values and provides guidance for how to implement strategies and guide us for ethical action, which I think is a step further than the previous code. These are our values. How do we act on them? This code helps specify how someone might actually act on these values.”

## Ethics Section works to share new code

The APHA Ethics Section offers opportunities to talk about public health ethics in practice, teaching and research. The Section’s page on APHA’s website is a repository of information on ethics, including news, events, committee updates and how to get involved. And it will be the landing page for information on the new code, said Greg Pavela, PhD, chair-elect of the Ethics Section. But that is not all.

“We want to solicit case studies from students, teachers and researchers about the importance of ethics to their work as a means to highlight the core values discussed in the new code of ethics,” said Pavella, an APHA member and assistant professor of health behavior at the University of Alabama School of Public Health.

Ethics Section members want to create a transparent conversation with stakeholders, using the APHA code as reference. Transparency creates openness, and openness leads to public trust, the bedrock of public health, Lee said.

“There is nothing more important in public health than trust from the public,” she said. “People trust people who they believe are doing the right thing. And what is the right thing in public health? We hope we captured that in this document.”

To download the new code of ethics, visit [bit.ly/phcodeofethics](http://bit.ly/phcodeofethics).

*A version of this story was published on APHA’s Annual Meeting Blog.*

*   Copyright The Nation’s Health, American Public Health Association