Reducing Social Inequalities in Health (SIH): Working together Toward a More Equitable, Healthier and Resilient Society

For ministries and organizations to be better positioned to collaboratively design new ways to reduce social inequalities in health (SIH), there is a need to clarify the pivotal role of reducing social inequalities across all levels of government and cross-sectoral efforts in preventing negative impacts on population health, and the potential contribution of multiple sectors to improving the health and well-being of the Québec population.​


The health of the population is closely tied to underlying social factors. Poverty, which involves the intersection of multiple forms of social inequalities, has repercussions that often extend beyond health to impact other social determinants of health in a negative downward spiral. The rise in social inequalities undermines the health status and well-being of the population, harms economic growth, and creates the potential for a breakdown in social cohesion.

Reducing social inequalities in health (SIH) is onl…

Utilitarianism in Public Health

How can we perceive and address ethical challenges in public health practice and policy? One way is by using ethical concepts to shed light on everyday practice. One does not have to be a specialist in ethics to do so. This document is part of a series of papers intended to introduce practitioners to some concepts, values, principles, theories and approaches that are important to public health ethics.

Many authors argue that public health interventions and programs are rooted in utilitarian ethics (Holland, 2007; Horner, 2000; Nixon & Forman, 2008; Rothstein, 2004; Royo‑Bordonada & Román-Maestre, 2015). For example, Royo-Bordonada and Román-Maestre write that “public health is in essence [...] utilitarian because it seeks to preserve the health status (something that contributes to the well-being of persons) of the maximum number of individuals possible, ideally the entire population” (2015, p. 3). Roberts and Reich (2002) also assert that the utilitarian p…

“Principlism” and Frameworks in Public Health Ethics

In this paper we will focus on principle-based approaches in public health ethics, comparing some of their features with those of principlism, the well-known and widely-used “four principles” approach in medical ethics.

We will first look at some of the main features of principlism and then with those features in mind we will turn to public health frameworks that rely on principles to see what they have in common as well as how they might differ.

Understanding and recognizing some of principlism’s main features can help practitioners to:

  • Better situate their own ethical deliberations in public health by seeing both the differences and the similarities between various ethical approaches;
  • Identify and make explicit principlist orientations guiding themselves or others in health care or in public health settings, whether in research or practice;
  • Having identified those orientations, communicate more effectively; and
  • Understan…

Introduction to Public Health Ethics 2: Philosophical and Theoretical Foundations

In this second1 of three briefing notes2 on public health ethics, we provide an overview of various philosophical and theoretical perspectives that have informed the development, evolution, and application of public health ethics throughout its short history. We believe it is important for public health practitioners to understand these ideas because they inform, either explicitly or implicitly, ethical decision making in public health practice. They also provide a foundation for the public health ethics frameworks that are presented and discussed in our third briefing note.3 

A broad range of ethical and political philosophies and theories have been used to provide justification for public health ethical decision making, particularly in situations in which competing values are at stake. The more traditional ethical theories and principles related to utilitarianism and contractaria…

Introduction to Public Health Ethics 3: Frameworks for Public Health Ethics

The first document1 in this series of briefing notes2 began with the observation that public health practitioners often struggle with ethical decisions in their practice but may not have relevant tools and resources to deal with these challenges. An assumption underlying this third paper is that by providing public health practitioners and decision makers with some guidance about practical public health ethics frameworks, they will be supported in making difficult ethical decisions that are unique to public health practice. In part, the management of ethical challenges will be implicitly or explicitly based on the kind of philosophical perspective one holds in relation to ethical problems in public health and it is important for practitioners to sort out what perspective makes sense to them, so they are guided in their own ethical decision making. The second document in this series3 presents the major philosophical and theoretical perspectives that p…

Solidarity in Public Health Ethics and Practice: Its Conceptions, Uses and Implications

Increasingly, the concept of solidarity is being brought into discussion as one of the principles and values that should guide the ethical practices of public health actors.1 Reflecting on ethical issues specific to solidarity as it relates to public health practice appears worthwhile because solidarity is a concept that first and foremost concerns groups or communities of people. Viewed from this perspective, solidarity is a value that, for some authors, seems more suited to playing a central role in public health ethics than do the more individualistic values, such as autonomy, which are usually regarded as central to biomedical or clinical ethics (Baylis, Kenny, & Sherwin, 2008; Dawson, 2011a; Prainsack & Buyx, 2011). This is why solidarity is frequently mentioned in frameworks that rely on values or principles to help guide ethical deliberations specific to the more community- and population-oriented public health issues…

Introduction to Public Health Ethics 1: Background

A public health ethics must begin with recognition of the values at the core of public health, not a modification of values used to guide other kinds of health care interactions (Baylis, Kenny, & Sherwin, 2008, p. 199).

Public health practitioners have long grappled with ethical issues in their practice but, until recently, there have been few relevant ethics frameworks that take into account the values base of public health.1 Historically, those involved in health care ethics and bioethics more generally have failed to provide public health practitioners with guidance geared to their unique ethical concerns. Until relatively recently, a rights-based deontological approach (Zahner, 2000), or the health care ethics principles of autonomy, beneficence, non-maleficence, and justice (Beauchamp & Childress, 1979), were invoked as the appropriate framework to support ethical public health p…

An Ethics Framework for Analyzing Paternalism in Public Health Policies and Interventions

The purpose of this document is to equip public health actors to conduct an ethical analysis of policies that are said to be paternalistic. It aims to provide the conceptual tools needed to identify paternalistic policies and assess the ethical burden with which they may be associated. The document also offers practitioners a clear and structured approach intended to guide ethical deliberation about paternalistic policies.

  • Paternalism in a nutshell
  • Some examples of policies called paternalistic
  • An approach and tools for the ethical analysis of paternalistic policies

This document is designed to provide an explicit and reasoned approach to conducting an ethical analysis of paternalistic public health policies. In choosing to frame the debate in terms of paternalism one risks assigning disproportionate weight to certain values within the deliberative process. The third step in our approach aims, among other things, to compensate for th…

Ethics Education in Public Health: Where Are We Now and Where Are We Going?

This summary, produced in English and in French by the National Collaborating Centre for Healthy Public Policy (NCCHPP), was originally intended to provide francophone readers with easy access to the key information from the original published article, a literature review of the state of ethics education in schools of public health. We have also produced this English-language version for those who wish a short summary of the findings from the literature review. The authors of the review are part of a research team at the École de santé publique de l’Université de Montréal (the School of Public Health at the University of Montréal) with whom the NCCHPP has partnered on different aspects of a larger project of which this is a part.

To learn more, visit the website of the National Collaborating Centre for Healthy Public Policy - NCCHPP (

How Can We (and Why Should We) Analyze the Ethics of Paternalistic Policies in Public Health?

The purpose of this document is to equip public health actors to conduct a critical and nuanced ethical analysis of public health policies or population-based interventions accused or suspected of being paternalistic.

To deepen understanding of paternalism and help public health actors conduct this type of ethical analysis, this document has been structured around five main questions: 

  • What is paternalism?
  • What are some healthy public policies that have been called paternalistic?
  • Why might we be attracted to policies or interventions that have been called paternalistic in public health?
  • Why might (or should) we be reluctant to accept public policies that are called paternalistic?
  • How might we conduct an ethical analysis of policies that are called paternalistic?

In the final, more practical, section, we offer a three-step approach to conducting a more nuanced ethica…