Exploring the bespoke approach to public health law and ethics that balances health, freedom, and fairness
When a pandemic strikes, who decides whether vaccines should be mandatory? How do we balance individual freedom with the collective good when implementing quarantine measures? These complex questions lie at the intersection of public health, ethics, and law—a territory that legal scholar Bernard Dickens has masterfully charted for decades.
As one of the pioneering figures in this interdisciplinary field, Dickens introduced a crucial insight: effective public health policies cannot follow a one-size-fits-all approach but must be "bespoke"—tailored to specific communities, threats, and contexts 1 3 .
At a time when public health decisions affect billions globally, understanding Dickens' approach provides not just academic insight but essential tools for navigating contemporary health crises. This article explores how Dickens' bespoke framework helps societies balance competing values of health, freedom, and fairness in crafting effective public health policies.
Dickens' concept of "bespoke public health" emphasizes that effective interventions must be tailored to specific circumstances rather than pulled from a standardized toolkit.
The term "bespoke"—traditionally referring to custom-made clothing—perfectly captures Dickens' central thesis: effective public health interventions must be tailored to specific circumstances rather than pulled from a standardized toolkit.
Unlike clinical ethics which focuses on individual practitioner-patient relationships, public health ethics operates at the population level, where decisions affect entire communities and societies .
A cornerstone of Dickens' work is distinguishing between two levels of ethical analysis:
Dickens championed the integration of legal analysis with ethical reasoning and public health science—an approach now known as interdisciplinary health law 4 .
He understood that effective public health policies must be grounded in robust scientific evidence while respecting legal frameworks and ethical values.
This methodology has inspired contemporary research networks like the Public Health, Ethics and Law Research Network (PHELN) 8 .
| Aspect | Microethics (Clinical) | Macroethics (Public Health) |
|---|---|---|
| Focus | Individual patient-practitioner relationships | Population-level health and policy |
| Primary Value | Patient autonomy | Community welfare and justice |
| Example | Respecting a patient's refusal of treatment | Implementing vaccination mandates for public safety |
| Decision Context | Clinical encounters | Policy development and implementation |
To understand Dickens' bespoke framework in action, we can examine his work on reproductive health, particularly his analysis of unsafe abortion as a public health emergency.
Unlike approaches that treat abortion as purely a private medical or moral issue, Dickens examined it through a public health ethics lens, focusing on population-level impacts and systemic solutions .
They began with epidemiological data showing that restrictive abortion laws correlate with higher rates of maternal mortality and morbidity, particularly in resource-poor countries.
They examined how different legal approaches to abortion (restrictive versus liberal) impacted public health outcomes.
They evaluated policies using public health ethics principles including equity, effectiveness, and proportionality.
Rather than advocating a single model, they suggested context-specific interventions that considered local legal systems, healthcare infrastructure, and cultural values.
The data revealed that restrictive abortion laws disproportionately harmed vulnerable populations, particularly poor women who lacked resources to access safer alternatives . This demonstrated how supposedly "neutral" laws could have deeply inequitable health impacts—a key concern for public health ethics.
| Legal Framework | Maternal Mortality Rates | Rate of Unsafe Abortions | Long-term Health Complications |
|---|---|---|---|
| Restrictive Laws | Significantly higher | High | Frequent |
| Liberal Laws | Lower | Low | Rare |
Reducing maternal mortality and morbidity through evidence-based policies.
Addressing disproportionate impacts on marginalized groups and vulnerable populations.
Grounding recommendations in scientific data and epidemiological evidence.
Ensuring restrictions (if any) are proportionate to legitimate public health goals.
Dickens' work has contributed to developing concrete ethical frameworks that guide public health decision-making, especially during crises.
| Principle | Definition | Application Example |
|---|---|---|
| Proportionality | Interventions should impose burdens proportionate to their expected benefits | Strict lockdowns might be proportionate during a lethal pandemic's peak but not as sustained policy |
| Equity | Benefits and burdens should be distributed fairly | Pandemic responses should not disproportionately burden disadvantaged communities |
| Least Restrictive Means | When multiple effective options exist, choose the one that limits freedoms least | Movement restrictions might be preferred over full lockdowns if equally effective |
| Transparency | Decision-making processes should be open and understandable | Public health agencies clearly explaining data behind mask mandates |
| Reciprocity | Society should support those who bear disproportionate burdens for public health | Providing economic support to workers affected by pandemic closures |
| Evidence-Based | Interventions should be grounded in scientific evidence | Implementing measures with proven effectiveness against specific pathogens |
Public health ethics recognizes that policies must balance three fundamental sets of values, each carrying moral weight 7 :
The primary goal of public health interventions
May conflict with economic interests or individual freedoms
Requires equitable distribution of benefits and burdens
Universal policies may have disproportionate impacts on marginalized groups
Respect for individual autonomy and liberty
Collective health measures may restrict personal choices
As Dickens recognized, different public health threats require different balancing of these values. A bespoke approach helps decision-makers navigate these tensions context-sensitively rather than applying rigid formulas.
The COVID-19 pandemic created unprecedented ethical challenges that directly reflected Dickens' concerns. Many policies—including prolonged lockdowns, school closures, and travel restrictions—raised fundamental questions about the proper balance between public health goals and other values 7 .
Researchers analyzing pandemic responses found that many policies diverged from established principles of public health ethics. For instance, the principle of using the "least restrictive alternative" was often violated through prolonged, stringent measures whose harms potentially outweighed benefits, especially after vaccine availability 7 .
The digital revolution in healthcare has created new ethical questions that Dickens' framework helps address. Health data are increasingly used for "practice analytics"—measuring and monitoring professional performance to improve healthcare quality 2 .
This practice raises complex questions about privacy, data accuracy, fairness in performance comparisons, and professional autonomy. Contemporary researchers have found that addressing these concerns requires the kind of interdisciplinary approach Dickens championed, balancing technical capabilities with ethical values and legal requirements 2 .
Dickens' work on reproductive health highlighted how public health laws can either advance or undermine global health equity. His analysis demonstrated how restrictive abortion laws created significant public health burdens in resource-poor countries .
This focus on how laws impact vulnerable populations continues to inform global health ethics today, particularly in addressing disparities in maternal mortality, infectious disease burden, and access to essential health services.
Bernard Dickens' great contribution to public health was recognizing that effective, ethical policies cannot be mass-produced but must be carefully tailored to specific contexts, threats, and communities. His interdisciplinary approach—weaving together legal analysis, ethical reasoning, and public health science—provides an essential framework for navigating the complex health challenges of our time.
The COVID-19 pandemic has starkly illustrated the consequences of losing sight of these nuanced principles, as many jurisdictions implemented blanket policies with insufficient attention to their ethical dimensions and unintended consequences 7 . Similarly, contemporary debates about using health data for performance analytics echo Dickens' insistence that technological capabilities must be guided by ethical considerations 2 .
As we face emerging public health threats—from pandemic preparedness to the ethical use of artificial intelligence in healthcare—Dickens' "bespoke" approach remains remarkably prescient. By asking not just "what works" but "what is just," "what is fair," and "what respects human dignity," we can craft public health policies that protect both population health and the fundamental values that make societies worth protecting.
The next time you hear a debate about vaccination mandates, privacy of health data, or pandemic restrictions, remember Dickens' insight: effective public health is always bespoke, never one-size-fits-all.