摘要：We consider the public health applications of genomic technologies as viewed through the lens of the public health code of ethics. We note, for example, the potential for genomics to increase our appreciation for the public health value of interdependence, the potential for some genomic tools to exacerbate health disparities because of their inaccessibility by the poor and the way in which genomics forces public health to refine its notions of prevention. The public health code of ethics sheds light on concerns raised by commercial genomic products that are not discussed in detail by more clinically oriented perspectives. In addition, the concerns raised by genomics highlight areas of our understanding of the ethical principles of public health in which further refinement may be necessary. IN RECENT YEARS, A PUBLIC health ethic has been distinguished from medical ethics. 1 – 3 Public health has been defined as what society does collectively to ensure that conditions exist for people to be healthy. 4 In public health ethics, the key relationship is between a government agency, such as a local health department, and the population it serves, whereas, in medicine, the physician–patient relationship is the basis of most ethical questions. While medical ethics often deal with the application of technologies to the beginning and end of life, ethical questions in public health often address the tension between the rights of individuals and the good of the overall community, democratic processes in determining health policies, the prevention of conditions that lead to poor health, and the protection of disenfranchised or marginalized populations. Contemporary discussions of public health ethics occur most often in the areas of HIV/AIDS, health disparities, and genomics. Genomics is the study of the functions and interactions of all the genes in the genome, including their interactions with environmental factors. 5 The ethical concerns in genomics are well-developed enough to have their own acronym, ELSI, which stands for the ethical, legal, and social implications. 6 The National Institutes of Health (NIH) has a National Genome Research Institute that includes the study and dissemination of ethical implications ( http://www.nhgri.nih.gov/PolicyEthics ). Genomics ELSI resource centers have been made available by the Centers for Disease Control and Prevention ( http://www.cdc.gov/genomics/links/ethical.htm ) and the World Health Organization ( http://www.who.int/genomics/elsi/en ). An underdeveloped topic in ELSI discussions is how medicine and public health might approach ethical questions differently. For example, one of the principles that is fundamental in medical ethics but subject to more contingencies in public health is autonomy. Because a physician has high social status and access to protected resources that may cure or harm, it is important to protect the patient from potential abuse and to guard his or her autonomy. But public health entails relationships between individuals in society as well as the relationship between the population and health agencies. In a community, 1 person’s actions can affect other people; one person’s infection can be another person’s exposure. In such instances, personal autonomy must be constrained for the social good. Thus, a principle that is fundamental in public health ethics is interdependence. This principle can have important implications for ethical perspectives on the applications of genomic tools.
