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. …