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Public Health or Clinical Ethics: Thinking beyond Borders

Published online by Cambridge University Press:  28 September 2012

Onora O'Neill
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Extract

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.

Type
Articles
Information
Ethics & International Affairs , Volume 16 , Issue 2 , September 2002 , pp. 35 - 45
Copyright
Copyright © Carnegie Council for Ethics in International Affairs 2002

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References

1 Beauchamp, Tom LChildress, James FPrinciples of Biomedical Ethics 1979 New YorkOxford University PressGoogle Scholar), became a standard text placing individual autonomy at the heart of medical ethics. Consistent opposition was voiced from an early date by Callahan, DanielAutonomy: A Moral Good, Not a Moral Obsession Hastings Center Report 1984 14 4042Google Scholar, and “Can the Moral Commons Survive Autonomy Hastings Center Report 1996 26 4142CrossRefGoogle Scholar.

2 Even discussions of health and justice have often been more concerned with the just distribution or allocation of clinical care to individuals, rather than with public health. See Daniels, Normanfust Health Care 1985 CambridgeCambridge University PressCrossRefGoogle Scholar).

3 Beauchamp, Tom LFaden, Ruth Rin collaboration with Nancy M. P. KingA History and Theory of Informed Consent 1986 New YorkOxford University PressGoogle Scholar).

4 For some of the differences see Hill, Thomas E Jr. The Kantian Conception of Autonomy in Dignity and Practical Reason in Kant's Moral Theory 1992 IthacaCornell University PressGoogle Scholar); and O'Neill, OnoraAutonomy and Trust in Bioethics 2002 CambridgeCambridge University PressCrossRefGoogle Scholar).

5 I leave aside the question of whether processes of democratic legitimation could show that some compulsion is acceptable, though we would probably not judge health and safety standards and requirements acceptable if they inflicted or permitted serious harms, however strongly they were endorsed by a democratic process.

6 Daniels, Just Health Care; Brock, Dan WBuchanan, AllenDaniels, NormanWikler, DanielFrom Chance to Choice: Genetics and Justice 2000 CambridgeCambridge University PressGoogle Scholar).

7 The scene may be changing. Recent literature on health inequalities is not confined to inequalities within states, and connections between normative reasoning and health inequalities are being drawn more frequently. See some of the papers in Leon, David AWalt, GillPoverty, Inequality and Health: An International Perspective 2001 OxfordOxford University PressGoogle Scholar); and in Anand, SudhirPeter, FabienneSen, AmartyaHealth, Ethics, Equity OxfordClarendon PressGoogle Scholar, forthcoming).

9 Nussbaum, Martha CWomen and Human Development: The Capabilities Approach 2000 New YorkCambridge University PressCrossRefGoogle Scholar).

10 Typically rights are justified by reference to well known public documents such as the UN Universal Declaration of Human Rights of 1948. As justifications such arguments from authority are pretty unconvincing. See Griffin, JamesDiscrepancies between the Best Philosophical Account of Human Rights and the International Law of Human Rights Presidential Address, Proceedings of the Aristotelian Society 2000 101 no. 1128Google Scholar.

11 For a significant example, see Bhuiya, AChowdhury, RMushtaque, A Do Poverty Alleviation Programmes Reduce Inequities in Health? The Bangladesh Experience in Leon and Walt Poverty, Inequality, and HealthGoogle Scholar.

12 O'Neill, OnoraA Question of Trust: The BBC Reith Lectures 2002 2002 CambridgeCambridge University PressGoogle Scholar).