Public Health Policymakers Want Input from Bioethicists

By Stacey Kusterbeck

Should a hospital require all employees to get an annual influenza vaccine? Who in a health system should get the first doses of a vaccine in limited supply? How should patient privacy and confidentiality be balanced against public health risk in infectious disease? What policies should hospitals adopt to reduce environmental hazards associated with plastic use? What is the role of academic medical centers in addressing health problems in the community?

“These are more than just public health questions. They are also ethical questions — questions not only about what we can do, but about what we should do,” says Lisa M. Lee, PhD, MA, MS, senior associate vice president for research and innovation at Virginia Tech and former executive director of the Presidential Commission for the Study of Bioethical Issues.

Bioethicists can play an important role in identifying and addressing any ethical considerations in these ways whenever a policy related to public health is implemented, says Lee:¹

• identifying key stakeholders;
• obtaining critical input from affected communities;
• weighing conflicting values;
• exploring disagreements; and
• identifying ethical approaches to formulate effective policies and practices.

“Identifying and articulating ethical dimensions of policy options can be extremely helpful in avoiding unanticipated consequences that could derail the policy. We’ve seen this again and again when the ethical dimensions of the work are not addressed. Failure, for example, to identify growing mistrust in science before and during the COVID-19 pandemic led to many failed efforts — from masks to vaccines — to contain the virus,” says Lee.

Bioethicists also are well-positioned to help with public health policymaking outside of their institutions, argues Lee. People make health decisions based not only on data and scientific evidence, but also their values and past experiences. Ethicists can help policymakers to think through these important concerns. “Doing so will help policymakers develop ethically and publicly defensible policies to prevent disease and promote health,” says Lee.

Ethicists often are trained in facilitation, mediation, or deliberation. “These skills can be helpful to work through the inevitable tensions that arise in public health and policy decision-making,” says Lee. However, for bioethicists in healthcare settings to take on a public health role, some additional training may be needed. “Clinical ethics differs from public health ethics in important ways. A bioethicist who does clinical ethics should have a thorough understanding of public health practice,” explains Lee.

While clinical medicine focuses on individual patients, public health practice focuses on communities and populations. Clinical medicine largely focuses on interventions after the onset of illness, whereas public health largely focuses on interventions to prevent a condition from occurring. “Because of these differences, the ethics — or decisions about how to weigh conflicting values and priorities — differ between clinical and public health ethics,” explains Lee.

Policymakers could seek input from bioethicists on any issues that involve complex value-laden questions, especially when there are conflicting values in play, according to Erika Blacksher, PhD, a research professor in the department of history and philosophy of medicine at the University of Kansas. How to ethically implement a new technology or treatment is a good example.

“Bioethicists study, teach, write, and debate about these very sorts of issues. They do this for questions that arise in delivery of medical care and the conduct of biomedical research — but also in public health, population health, health policy, environmental health, and beyond,” says Blacksher.

Bioethicists consider multiple perspectives when developing recommendations. “Thus, bioethicists are likely to speak not only to what they think about the matter but also about what others think. And they can situate their views within that broader context,” says Blacksher. Policymakers unfamiliar with the work of bioethicists may not realize that there are scholars and researchers who specifically study the ethics of issues relevant to public policy, adds Blacksher. For bioethicists who want to take on this role, Blacksher recommends taking these steps:

• focusing research and publishing directly on questions of public policy;
• networking with bioethicists who have careers in public health policy; and
• informing hospital leadership that their expertise extends to public health policies.

Whether ethicists need additional training in public health depends on what role the ethicist is going to have in the policymaking process, according to Gerard Vong, DPhil, director of the Master of Arts in Bioethics Program at Emory University. In 2024, Vong helped to develop a policy at the university health system to address a shortage of intravenous fluid that occurred after a manufacturing plant flooded during Hurricane Helene. Since the shortage affected people throughout the hospital system, the collaborative working on the policy included ethicists, legal counsel, multiple medical specialties, health informatics, and administrative leadership. Each person contributed based on their specific area of expertise. “By the time I was on this committee, I had years of experience developing policy at the hospital level — plus it was a large collaborative working together, so I didn’t need any additional expertise,” says Vong.

It’s a different story if the ethicist is leading the writing of policy on a public health topic. “Moral philosophers, while deeply knowledgeable about theory, may need more training and education related to logistics, relevant laws, and implementation,” says Vong.

Bioethicists may need to educate policymakers about what they can offer in terms of expertise. “One challenge with some policymakers is that they assume that any ethicist is well-placed to respond to any ethical issue. As bioethicists know, there are important differences in expertise,” says Vong. Ethics expertise in scarce resource allocation is very different, for example, from expertise in the provision of ethical care of patients with stigmatized health conditions (such as mental illness or human immunodeficiency virus).

Some policymakers already know what they want to do and just are seeking a “rubber stamp” approval from an ethicist. “That’s an opportunity for the ethicist to educate the policymaker about the role and importance of ethics beyond the review and approval process,” says Vong.

Many public health policymakers want to get input from bioethicists, but few actually do so, according to a recent survey.² Researchers surveyed 459 local government elected policymakers, 288 local managers, and 358 state and local civil service workers about interactions with bioethicists. “A minority of policymakers seek counsel from bioethicists when facing policy challenges in their work. But many policymakers express an unmet desire for such counsel,” says Andrew G. Shuman, MD, FACS, HEC-C, one of the study authors and professor and chief of the Clinical Ethics Service at the University of Michigan Medical School.

Only 12% of elected policymakers, 6.6% of managers, and 14.2% of civil servants reported recently interacting with a bioethicist. However, 40.1% of elected policymakers, 40% of managers, and 47.9% of civil servants stated that they would like to have more direct engagement with bioethicists. Policymakers thought that bioethicists potentially could help with a wide variety of topics, including homelessness, public health, mental health, infectious disease, youth health, and substance use disorders. ”We encourage bioethicists to think regionally, not just nationally,” says Shuman. Ethicists can attend open public meetings (such as those in county or municipal government) to connect with policymakers.

Respondents also reported reasons they would hesitate to engage with bioethicists. Some perceived that bioethicists would not provide practical information or that bioethicists would push a political agenda.

“Bioethicists must ensure they are responsive to policymakers’ specific needs and be explicit about how their counsel reflects values that transcend partisanship, without creating ‘us versus them’ polarization,” says Shuman. Bioethicists can do this by narrowly focusing on the specific issues that concern policymakers.

Use of artificial intelligence (AI) in policymaking processes is one timely topic that policymakers need bioethicists’ input on, says Selena E. Ortiz, PhD, MPH, an associate professor of health policy and administration, demography, and public policy at The Pennsylvania State University. Of particular concern from an ethics standpoint is AI use that leads to social and health policies that directly affect the health and well-being of vulnerable communities, says Ortiz. “Bioethicists are critical partners in identifying ethical issues that must be addressed, not only when using AI to generate policies that have real-world implications, but also in the implementation and evaluation of policy,” says Ortiz. A related topic is the increasing use of AI tools among consumers and healthcare professionals to inform healthcare decision-making. “Decisions as to whether healthcare organization leaders develop policies that monitor or limit the use of such tools would be greatly informed through consultation with bioethicists,” says Ortiz.

To be most helpful in this regard, Ortiz recommends that bioethicists become familiar with public health ethical principles. For example, in 2020 the American Public Health Association published a revised code of public health ethics.³ The code emphasizes values such as health justice, professionalism, and community engagement. “It could be a valuable framework for bioethicists to use [for] framing discussions about complex ethical issues, aiding decision-making, and promoting ethical action in policymaking,” offers Ortiz.

Although a lot of policy involves health issues, elected officials and their staff typically lack professional background in this area. “While elected officials make decisions, most research is conducted by their staffers, who are usually under age 30 [years] and with bachelor’s degrees,” says Craig M. Klugman, PhD, a professor of bioethics and health humanities at DePaul University and ethics committee member at Northwestern Memorial Hospital. In college, Klugman briefly interned in a Congressional office in Washington, DC, which entailed summarizing bills and making recommendations to the congressperson about how to vote. “There is a whole range of ways in which ethicists can work with policymakers,” reports Klugman. Ethicists can reach out to staffers and offer to provide background on specific bioethics topics. “To talk to legislators, you simply need to call their offices and offer your time and knowledge. Offer to take them to breakfast and give them an update on a topic,” advises Klugman.

Many bills and topics will, at some point, get a hearing through a legislative committee or subcommittee. This presents another opportunity for bioethicist engagement. “Bioethicists can provide testimony before a legislative committee meeting or can even just be present for the discussion of a specific bill,” says Klugman.

Although elected officials vote on laws, agencies and departments create rules and regulations to determine how those laws are implemented. Many rules and regulations are subject to a public comment period. Bioethicists can contribute to the discussion by submitting written comments through online forms, suggests Klugman. “When I worked with the Nevada Center for Ethics & Health Policy, we were working with the Secretary of State’s office to create a statewide advance directive repository. Many of us gave testimony before the health subcommittee. Other bioethicists have given testimony before Congress,” says Klugman.

If working with policymakers directly is not of interest to a bioethicist or violates a hospital rule, writing an editorial is another option. “Writing op-eds can propel you as a public thought leader to help fashion the discussion and, sometimes, the legislation,” explains Klugman. In talking with a lobbyist for the Texas Medical Association about an online advance directive project, Klugman noted that it required electronic signatures, which were not then legal. As a result of Klugman’s observation, lawmakers authorized such signatures a few months later. “Choose legislators who serve on a health subcommittee, or who have experienced health challenges in their own families. They will be most open to hearing our stories and our experiences,” says Klugman.

Another level of involvement for bioethicists is serving on government advisory boards at local, county, state, and even federal levels. “Members of the public are sometimes required and sometimes invited to be part of task forces and other advisory groups,” says Klugman, who was part of two such groups, which created pandemic response plans and crisis standards of care guidelines.

“Perhaps the most time-intensive but greatest impact step one can take to work on policy is to run for office yourself. Only one bioethicist, David Orentlicher, has taken this step, being elected to the Indiana legislature,” observes Klugman.

Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.

References

1. Lee LM. Ethical competencies for public health personnel. Ethics Med Public Health. 2018;4:21-26.

2. Levine AS, Shuman AG. Policymakers’ engagement with ethicists to improve public health in the United States. Prev Med Rep. 2025;58:103213.

3. Lee LM, Ortiz SE, Pavela G, Jennings B. Public health code of ethics: Deliberative decision-making and reflective practice. Am J Public Health. 2020;110(4):489-491.