Public Health or Clinical Ethics: Thinking beyond Borders

By O'Neill, Onora | Ethics & International Affairs, October 2002 | Go to article overview

Public Health or Clinical Ethics: Thinking beyond Borders


O'Neill, Onora, Ethics & International Affairs


Most work in medical ethics across the last twenty-five years has centered on the ethics of clinical medicine. Even work on health and justice has, in the main, been concerned with the just distribution of (access to) clinical care for individual patients. By contrast, the ethics of public health has been widely neglected. This neglect is surprising, given that public health interventions are often the most effective (and most cost-effective) means of improving health in rich and poor societies alike.

In this essay I explore two sources of contemporary neglect of public health ethics. One source of neglect is that contemporary medical ethics has been preoccupied--in my view damagingly preoccupied--with the autonomy of individual patients. Yet individual autonomy can hardly be a guiding ethical principle for public health measures, since many of them must be uniform and compulsory if they are to be effective. A second source of neglect is that contemporary political philosophy has been preoccupied--in my view damagingly preoccupied--with the requirements for justice within states or societies, and (until very recently) has hardly discussed justice across borders. Yet public health problems often cross borders, and public health interventions have to measure up to the problems they address.

An ethically adequate approach to health questions needs to look beyond the clinical context, and beyond the boundaries of states and health care systems. Health ethics must cover more than clinical ethics; accounts of health and justice must cover more than the just distribution of clinical care within health care systems.

INDIVIDUAL AUTONOMY AND PUBLIC HEALTH

Contemporary medical ethics emerged in rich societies, in particular in the United States, during the 1970s. Unsurprisingly, it took for granted the medical practices and institutions of such societies. The new medical ethics addressed ethical problems that were typical of professionalized, hospital-based clinical practice that could provide expensive, high-tech medical interventions. Traditional one-to-one, long-term physician-patient relationships, based on patient trust and physician beneficence, did not fit well into the new clinical settings, which deployed large teams of professionals in the care of individual patients. The new medical ethics advocated an end to all forms of medical paternalism, in favor of what is now usually called patient autonomy. (1)

The various conceptions of individual autonomy deployed in medical ethics view it as a predicate of individual persons. Autonomous patients are independent agents who decide for themselves whether they will accept or refuse treatment; professionals are to respect patients' autonomy and undertake treatment only on the basis of informed consent. Compulsion and coercion are always unacceptable in clinical practice. The new medical ethics had relatively little to say about public health, where interventions are often (and sometimes necessarily) compulsory. (2)

Even in clinical practice, unqualified demands to respect individual autonomy proved problematic. As sociologists and anthropologists of medicine have long pointed out, the individualistic frameworks within which conceptions of individual autonomy can most easily be thought of as central to medical ethics correspond poorly with the realities of clinical practice. Professionals are linked in complex institutional networks; patients come encumbered with family and other responsibilities.

Nor was individualism the only problem. Since ill health so often limits individual independence in minor and major ways, it was harder to build respect for individual autonomy into medical practice than into most other areas of life. Children and the senile, the comatose and the confused, the cognitively impaired and the mentally disturbed, and all of us when we are feeling ill and frail, have reduced or no capacity for individual autonomy. …

The rest of this article is only available to active members of Questia

Already a member? Log in now.

Notes for this article

Add a new note
If you are trying to select text to create highlights or citations, remember that you must now click or tap on the first word, and then click or tap on the last word.
One moment ...
Default project is now your active project.
Project items

Items saved from this article

This article has been saved
Highlights (0)
Some of your highlights are legacy items.

Highlights saved before July 30, 2012 will not be displayed on their respective source pages.

You can easily re-create the highlights by opening the book page or article, selecting the text, and clicking “Highlight.”

Citations (0)
Some of your citations are legacy items.

Any citation created before July 30, 2012 will labeled as a “Cited page.” New citations will be saved as cited passages, pages or articles.

We also added the ability to view new citations from your projects or the book or article where you created them.

Notes (0)
Bookmarks (0)

You have no saved items from this article

Project items include:
  • Saved book/article
  • Highlights
  • Quotes/citations
  • Notes
  • Bookmarks
Notes
Cite this article

Cited article

Style
Citations are available only to our active members.
Buy instant access to cite pages or passages in MLA, APA and Chicago citation styles.

(Einhorn, 1992, p. 25)

(Einhorn 25)

1. Lois J. Einhorn, Abraham Lincoln, the Orator: Penetrating the Lincoln Legend (Westport, CT: Greenwood Press, 1992), 25, http://www.questia.com/read/27419298.

Cited article

Public Health or Clinical Ethics: Thinking beyond Borders
Settings

Settings

Typeface
Text size Smaller Larger Reset View mode
Search within

Search within this article

Look up

Look up a word

  • Dictionary
  • Thesaurus
Please submit a word or phrase above.
Print this page

Print this page

Why can't I print more than one page at a time?

Help
Full screen

matching results for page

    Questia reader help

    How to highlight and cite specific passages

    1. Click or tap the first word you want to select.
    2. Click or tap the last word you want to select, and you’ll see everything in between get selected.
    3. You’ll then get a menu of options like creating a highlight or a citation from that passage of text.

    OK, got it!

    Cited passage

    Style
    Citations are available only to our active members.
    Buy instant access to cite pages or passages in MLA, APA and Chicago citation styles.

    "Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn, 1992, p. 25).

    "Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn 25)

    "Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences."1

    1. Lois J. Einhorn, Abraham Lincoln, the Orator: Penetrating the Lincoln Legend (Westport, CT: Greenwood Press, 1992), 25, http://www.questia.com/read/27419298.

    Cited passage

    Thanks for trying Questia!

    Please continue trying out our research tools, but please note, full functionality is available only to our active members.

    Your work will be lost once you leave this Web page.

    Buy instant access to save your work.

    Already a member? Log in now.

    Oops!

    An unknown error has occurred. Please click the button below to reload the page. If the problem persists, please try again in a little while.