A tranquil Saturday morning in Cambridge, and the conflicting goals of public health & clinical ethics.

It was a tranquil Saturday morning in Cambridge, Massachusetts…I was reading the news sitting at the kitchen table when I heard a noise, as of something falling. A moaning and grunting sound followed. I stood up and went to the window to to check the cause of the noise, expecting to see a dog or another animal. What I did not expect to see was a half dressed man, lying flat on his back in the internal courtyard, arms widespread, and blood coming out of his mouth.
As it turned out later, he had fallen, most probably hungover from a party, from the third floor balcony. What does this has to do with the goals of public health? (By the way, against all odds of falling down from a balcony on the third floor, the guy turned out to be ok). Public health’s main goal is supposed to be the protection of, as a matter of fact, the health of the public, ie of the population. In order to reach this goal, public health policy makers build appropriate infrastructure, make sure that the water we drink is clean, take care of the roads we drive in, and so on and so forth. Public health promotion includes also bans, such as smoking prohibitions, junk food bans, and no drink & drive regulations. To what extent should interventions aimed at limiting dangerous behaviors for the individuals be limited? Does the promotion of health population include prohibiting drinking parties on private homes’ balconies? Would such interventions be legitimate?

According to Ron Bayer (Mailman School of Public Health, Columbia University), speaker at the 6th International Bioethics Conference on New strategies in health promotion, (Harvard, Boston, April 28-29, 2011), the answer is a definite YES.
Ron Bayer, who is also associate editor for the Journal of Public Health Ethicsdiscussed the aims of public health, and the necessity to distinguish them from the aims of clinical ethics. As put by Bayer, John Stuart Mill and the harm principle is not a good place to start reasoning, when thinking about public health (though it is a place that needs to be acknowledged). Indeed, the aims of public health are not to respect the individual autonomy, but to advance the health of population. Ethics, as emerged in clinical ethics, is strongly autonomy focused and Mill-based, and focuses on the individual. Public Health ethics instead is focused on population. According to Bayer, the problems arose when clinical ethicists migrated to public health ethics and tried to apply to the latter the same principles that they were using in the former. That couldn’t possibly work, as when dealing with populations the focus needs to be elsewhere, not on the autonomy. Elsewhere meaning the health of the population, which requires utilitarian reasoning and paternalist justifications in order to be accomplished. Along these lines, the starting point when discussing the goals and ethics of public health is to acknowledge that paternalism is an important element in public health, contrary to clinical ethics. Then, taking that element as a starting point, the question to address in public health becomes: what level of coercion and of public intrusion are we prepared to take in order to enforce public health paternalist policies, as complete smoking bans in public places (as the one enforced in NYC), or parties on private houses’ balconies in Cambridge?

Acknowledging the paternalistic element, though, only opens up the ethical discussion, as other elements need to be taken into account, one being acknowledging Mill’s principle and the autonomy of the patient. Respecting the autonomy of the patient while promoting the health of the population may turn out tricky. In this sense, the goals of clinical ethics and of public health may be conflicting, and as spelled out by Jon Wolff (Director of the Centre for Philosophy, Justice and Health, University College London) in the concluding ethical remarks of the Harvard conference, it is not clear yet what the goals of the health promotion strategies are: promoting individual autonomy, or promoting population health? Without making clear which one of the goals should take precedence, it becomes difficult to spell out what are the “ethical pitfalls” (as the title of the conference reads) of the incentives (be them carrots or sticks), and how to “steer” clear of them.

Further reading

An article by Christian Munthe on the JPHE and titled “The Goals of Public Health: An Integrated, Multidimensional Model” touches a similar point. As put by Munthe, while promoting population health (1) has been the classic goal of public health practice and policy, in recent decades new objectives in terms of autonomy (2) and equality (3) have been introduced. These different goals may conflict severly in several ways, leaving serious unclarities both regarding the normative issue of what goal should be pursued by public health, what that implies in practical terms, and the descriptive issue of what goal that actually is pursued in different contexts. You can read the article by Christian Munthe here.

The issue of July 2009 of the journal of Public Health Ethics explores the issues revolving around the role of political philosophy in public health ethics. You can read the editorial by Angus Dawson here, or see the table of contents of the July 2009 issue.

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