Every day public health practitioners are faced by many dilemmas in their practice. The discussions in the chapters in this book have addressed some of the old and new areas of ethical debate in public health. Developing coherent and effective health promotion messages is clearly important, as is thinking about how we should respond to new technologies such as new vaccines, and potential public health threats such as pandemic flu and resistant strains of TB. There are also difficult debates about the nature of evidence in public health and the extent to which evidence can and even should be the main guide for policy and practice. Public health has been described as ‘social action’ and, therefore, governed by different paradigms from clinical medecine, and evidence should consequently play a different role. What is certain and clearly described by the chapters of this book is that ethics should be a primary concern of public health. Angus Dawson argued in Chapter Twelve that public health ethics needs to be built up from public health practice. This is a central theme of the book.

Much revolves around the role of government, as it sets the context within which public health policies and practice are developed and implemented. Steve Holland argued in his chapter that it is important to examine the legitimate circumstances of public health action by governments in relation to the individual and the wider community. This is a view echoed by the Nuffield Council on Bioethics, which supported the concept of the ‘stewardship role’ of government. Stewardship is defined as the social contract between government and its people, whereby government processes are performed in trust for the people and founded on principles of ethics as well as efficiency (Saltman and Ferroussier-Davis, 2000). The very nature of stewardship implies a stronger activist role by government to ensure that ethically sound and efficient policy is formulated and delivered for the greatest good. Stewardship implies that governments have the responsibility not only to use public funds in a responsible manner, but also to invest these in ways that address suffering among its poorest people and reduce inequality among its citizens.