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Does Public Health Have a Personality (and If So, Does It Matter If You Don't Like It)?

Abstract

“Dissecting Bioethics,” edited by Tuija Takala and Matti Häyry, welcomes contributions on the conceptual and theoretical dimensions of bioethics.

The section is dedicated to the idea that words defined by bioethicists and others should not be allowed to imprison people's actual concerns, emotions, and thoughts. Papers that expose the many meanings of a concept, describe the different readings of a moral doctrine, or provide an alternative angle to seemingly self-evident issues are therefore particularly appreciated.

The themes covered in the section so far include dignity, naturalness, public interest, community, disability, autonomy, parity of reasoning, symbolic appeals, and toleration.

All submitted papers are peer reviewed. To submit a paper or to discuss a suitable topic, contact Tuija Takala at tuija.takala@helsinki.fi.

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1. It is false to say (though sometimes implied) that ethical issues in public health have been overlooked until recently: for example, see Beauchamp DE. Public health: Alien ethic in a strange land? American Journal of Public Health 1975;65(12):1338–9. However, over the past decade or so, there has been a rapid growth within bioethical literature, with “public health ethics” presenting itself as a field in its own right and an area that demands renewed focus: for example, see Beauchamp DE, Steinbock B, eds. New Ethics for the Public's Health. New York: Oxford University Press; 1999; Kass N. An ethics framework for public health. American Journal of Public Health 2001;91(11):1776–82; Roberts MJ, Reich MR. Ethical analysis in public health. The Lancet 2002;359:1055–9; Gostin LO. Public Health Law and Ethics—A reader. Berkley: University of California Press; 2002; Thompson A, Robertson A, Upshur R. Public health ethics: Towards a research agenda. Acta Bioethica 2003;9(2):157–63; Jennings B. Frameworks for ethics in public health. Acta Bioethica 2003;9(2):165–76; Benatar SR, Daar AS, Singer PA. Global health ethics: The rationale for mutual caring. International Affairs 2003;79(1):107–38; Anand S, Peter F, Sen A, eds. Public Health, Ethics, and Equity. Oxford: Oxford University Press; 2004; Boylan M, ed. Public Health Policy and Ethics. Dordrecht: Kluwer Academic Publishers; 2004; Bayer R, Gostin LO, Jennings B, Steinbock B, eds. Public Health Ethics: Theory, Policy, and Practice. Oxford: Oxford University Press; 2006; Dawson A, Verweij M, eds. Ethics, Prevention, and Public Health. Oxford: Oxford University Press; 2007.

2. Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva: World Health Organization Press; 2008.

3. Beauchamp DE. Public health as social justice. Inquiry 1976;13:1–14; Daniels N. Just Health—Meeting Health Needs Fairly. Cambridge, UK: Cambridge University Press; 2008; Gostin LO, Powers M. What does social justice require for the public's health? Public health ethics and policy imperatives. Health Affairs 2006;25:1053–60; Powers M, Faden R. Social Justice: The Moral Foundations of Public Health and Health Policy. Oxford: Oxford University Press; 2006.

4. Schmidt H. Patients’ charters and health responsibilities. British Medical Journal 2007;335:1187–9.

5. Marcel Verweij and Angus Dawson offer a useful and insightful discussion of the descriptive/normative divide in accounts of public health, and the implications of choice of definition, in Verweij M, Dawson A. The meaning of “public” in “public health.” In: Dawson A, Verweij M, eds. Ethics, Prevention, and Public Health. Oxford: Oxford University Press; 2007. See especially pp. 14–20.

6. This is not always the case: Mark Rothstein, for example, argues on pragmatic grounds that public health ought to have a narrow “jurisdiction,” restricted to that of the public health agencies’ legal authority: Rothstein MA. Rethinking the meaning of public health. Journal of Law, Medicine and Ethics 2002;30:144–9. Although in the current essay I, too, advocate a narrow role for public health, I do so in a distinct manner to Rothstein. For one thing, I do not consider public health to be something with a jurisdiction. For another, unlike Rothstein, I do think that the bigger picture is usefully considered and dealt with in a normative (legal and ethical) analysis and embrace a role for experts in public health in informing the whole debate. It is my view that this all-things-considered analysis is precisely what is needed in bioethics in order that our conceptions be properly thought through. Beyond this very brief footnote, the current essay does not speak directly to Rothstein's arguments. For a direct critique of Rothstein's position and a defense of it, see, respectively, Goldberg DS. In support of a broad model of public health: Disparities, social epidemiology and public health causation. Public Health Ethics 2009;2(1):70–83; Rothstein MA. The limits of public health: A response. Public Health Ethics 2009;2(1):84–8.

7. Jennings B. Public health and civic republicanism: Toward an alternative framework for public health ethics. In: Dawson A, Verweij M, eds. Ethics, Prevention, and Public Health. Oxford: Oxford University Press; 2007:31.

8. Baylis F, Kenny N, Sherwin S. A relational account of public health ethics. Public Health Ethics 2008;1(3):196–209 at p. 206.

9. Bayer R, Gostin LO, Jennings B, Steinbock B. Introduction: Ethical theory and public health. In: Bayer R, Gostin LO, Jennings B, Steinbock B, eds. Public Health EthicsTheory, Policy, and Practice. Oxford: Oxford University Press; 2007:4.

10. To an extent, our perception of the “conflict” alluded to in the quotation will depend on how we interpret “ethics” in this context. If public health ethics and medical ethics are conceived as professional ethics, for example, as the normative underpinnings expressed in professional regulatory codes, there may be superficial, or even substantial, conflict between public health ethics and medical ethics. However, I fail to see that critical ethics can conflict with itself: as public health practices and medical practices ought to be governed according to the same, proper, overarching normative theory (whatever it may be), there cannot be a real conflict between the ethics of each. If there seems to be a conflict, that is simply an indication that ethical conclusions on at least one of them are wrong.

11. Gostin LO. Public Health Law: Power, Duty, Restraint (2nd ed.). Berkeley: University of California Press; 2008:41.

12. Nuffield Council on Bioethics. Public HealthEthical Issues. London: Nuffield; 2007:18. It is questionable that the Council's claim that the “stewardship model” it advances in this report really does add anything substantive to the kind of liberal framework it seeks to move beyond: Coggon J. Harmful rights doing? The perceived problem of liberal paradigms and public health. Journal of Medical Ethics 2008;34(11):798–801. Angus Dawson and Marcel Verweij have also been critical of the report: Dawson A, Verweij M. The steward of the Millian state. Public Health Ethics 2008;1(3):193–5. Two members of the Council's Working Party on this report and the secretary to the Working Party have responded to the concerns raised in these pieces: Baldwin T, Brownsword R, Schmidt H. Stewardship, paternalism and public health: Further thoughts. Public Health Ethics 2009;2(1):113–6.

13. See note 8, Baylis et al. 2008:200. Reflections such as this, which provide the grounds of many critiques on public health, are welcome and do not (if anyone suggests otherwise) find themselves solely within the feminist literature. For example, this concern is well reflected in the discussion of moral agents in Griffin J. On Human Rights. Oxford: Oxford University Press; 2008:35, where he says: “Our aim must be the more modest one of understanding not the autonomy of a spare, abstract self, but the autonomy of Homo sapiens.” See also Jennings B. Autonomy and difference: The travails of liberalism in bioethics. In: Davies R, Subedi J, eds. Bioethics and Society. New York: Prentice Hall; 1998; Jennings B. From the urban to the civic: The moral possibilities of the city. Journal of Urban Health 2001;78(1):88–102; Gaylin W, Jennings B. The Perversion of Autonomy: Coercion and Constraints in a Liberal Society (2nd ed.). Washington, DC: Georgetown University Press; 2003.

14. See note 8, Baylis et al. 2008:199.

15. See, e.g., note 13, Gaylin, Jennings 2003; Jennings B. The liberalism of life: Bioethics in the face of biopower. Raritan 2003;22(4):132–46.

16. See note 13, Jennings 2001:91.

17. See note 13, Jennings 2001. See also Jennings B. Bioethics and democracy. The Centennial Review 1990;34(2):207–26.

18. See note 7, Jennings 2007.

19. See the criticisms in, e.g., O'Neill O. Public health or clinical ethics: Thinking beyond borders. Ethics and International Affairs 2002;16(2):35–45; Brazier M. “Do no harm”—Do patients have responsibilities too? Cambridge Law Journal 2006;65(2):397–422; see note 17, Jennings 1990.

20. Given the goals of the Nuffield Council and its stated misgivings concerning autonomy in bioethics, it would have done well to look for an in-principle sustainable theory of liberalism, such as that advanced by Joseph Raz (e.g., in Ethics in the Public Domain. Oxford: Clarendon; 1994), which has all the strengths the Nuffield Council sought, avoids all the weaknesses, and attaches itself to an ideal of objective morality: See note 12, Coggon 2008.

21. The Nuffield Council report runs from a similar idea, working from libertarianism to collectivism (either in the form of a collective contract or in the form of a model to maximize collective utility): See note 12, Nuffield Council on Bioethics 2007:13–4.

22. For example, see note 19, O'Neill 2002.

23. For example, see MacKenzie C, Stoljar N, eds. Relational Autonomy: Feminist Perspectives on Autonomy, Agency, and the Social Self. Oxford: Oxford University Press; 2000.

24. See note 8, Baylis et al. 2008:206.

25. One way in which analysts may dispute this is by claiming that “the public” is its own entity, rather than just the sum of its members. See, e.g., note 7, Jennings 2007, especially pp. 36 and 48–58. I am not able here to offer such arguments the treatment that they deserve, but would note one theoretical problem that might present itself: if the public is a distinct concept, whatever health means, it can hardly mean the same thing for this more-than-its-embodied-parts thing (the public) as it does for embodied agents such as humans. In other words, there is no reason automatically to suppose that a healthy public comprises healthy individuals: the word healthy in such a claim would not necessarily have even a similar meaning.

26. See note 8, Baylis et al. 2008:206 (emphasis added).

27. In line with Gostin, see text to note 11.

28. Fox T. Purposes of medicine. The Lancet 1965;7417:801–5.

29. Munthe C. The goals of public health: An integrated, multidimensional model. Public Health Ethics 2008;1(1):39–52.

30. Winslow C-EA. The untilled fields of public health. Science 1920;51(1306):22–33 at p. 30.

31. See note 12, Nuffield Council on Bioethics 2007:v.

32. Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1988:40.

33. See note 32, Institute of Medicine 1988:1.

34. See note 1, Gostin 2002:6.

35. Mann JM. Medicine and public health, ethics and human rights. Hastings Center Report 1997;27:6–13 at p. 12.

36. Callahan D, Jennings B. Ethics and public health: Forging a strong relationship. American Journal of Public Health 2002;92(2):169–76 at p. 169.

37. Skrabanek P. The Death of Humane Medicine and the Rise of Coercive Healthism. Bury St. Edmunds, UK: St. Edmundsbury Press; 1994.

38. See note 5, the analysis in Verweij, Dawson 2007.

39. Häyry M. Public health and human values. Journal of Medical Ethics 2006;32(9):519–21.

40. For example, see Beauchamp DE. The neglected tradition of public health. Hastings Center Report 1985;15(6):28–36.

41. As indeed they are in the analysis of Beauchamp (see note 40, Beauchamp 1985) and others mentioned in this essay.

42. See, e.g., Gostin LO, Stone L. Health of the people: The highest law? In: Dawson A, Verweij M, eds. Ethics, Prevention, and Public Health. Oxford: Oxford University Press; 2007. They argue that “[c]ertainly, the power and importance of individual freedom is beyond dispute,” but end the same paragraph with “[e]ach member of society owes a duty—one to another—to promote the common good. And each member benefits from participating in a well-regulated society that reduces risks that all members share. The protection and satisfaction gained from living in a community where public health is recognized as an important value should outweigh the individual self-interest in looking out only for oneself” (p. 62). Gostin and Stone are not arguing that all health interests should always prevail, but do continue, for example, by saying that “[t]he public health community takes it as an act of faith that health must be society's overarching value” (p. 66), and go on to argue that “political officials are at least putatively committed to securing health for the population, and members of the community are committed to bear the necessary burdens. The collective efforts of the body politic to protect and promote the population's health represent a central theoretical tenet of what we call public health ethics” (p. 68).

43. In Re T (Adult: Refusal of Treatment) [1993] Fam 95, 102.

44. For a consideration of the interplay between the liberal model that supports this and the resultant position for healthcare decisionmaking, see Coggon J. Best interests, public interest, and the power of the medical profession. Health Care Analysis 2008;16(3):219–32.

45. For example, medical ethics, public health ethics, and so forth.

46. See note 7, Jennings 2007. Bruce Jennings’ analyses provide excellent groundings for normative evaluations in public health ethics. In particular, see also note 36, Callahan, Jennings 2002, and note 1, Jennings 2003.

47. It might be argued that a sufficiently developed account of liberalism will no longer be liberalism; it will be too far removed (see note 13, Jennings 2001:93). Instinctively, I disagree with this, but ultimately I anyway am less concerned with maintaining the term liberalism, and more concerned with the substance and import of the theory.

48. See further the arguments in Wilson J. Not so special after all? Daniels and the social determinants of health. Journal of Medical Ethics 2009;35(1):3–6.

49. See note 7, Jennings 2007:31, emphasis added.

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Cambridge Quarterly of Healthcare Ethics
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