A personalist approach to public-health ethics
Carlo Petrini a, Sabina Gainotti b
The past and present of public health
In developed countries, where high standards of living have been achieved, public health is often viewed as a sort of secular faith providing good advice (on nutrition, physical health, longevity, etc.) and imposing rules (wearing seatbelts, refraining from smoking in public places, etc.) for the protection of collective health. This moralizing vocation of public health has been much described in the literature.1 In this respect, the debate over information, persuasion, privacy and their ethical implications has also become much broader.2
These features of public health are a development of its secular functions, traditionally carried out by doctors (if public health is linked with the existence of registry data on births, marriages and deaths).3 Indeed, the main idea of public health, that implicitly crosses centuries of human history, can be summed up in a definition by Anne Fagot-Largeault: “a population in good health reproduces well, provides strong soldiers, good workers and fertile women”.4
Only in recent years has the concept of public health been widened to incorporate the idea of global health. The latter can be associated with the well-known definition of health by WHO.5 As a consequence, the role of public health that was previously limited to communicable disease control6 shifted to a broader-spectrum action that is more overt in developed countries. Today public health is primarily related to epidemiology7 but also to social, economical and political matters.8,9 The widening of public health’s scope (so broad as to engender some confusion), together with the rise of new emergencies in epidemiology,10 also led some scholars to reflect on the opportunity for public health to return to dealing mainly with communicable disease control, leaving other areas of intervention to other disciplines.11 However, the development of public health is by now a consolidated reality;12 this means that public health is located at a crowded intersection among risks, health effects and prevention.13
Codes of ethics and bioethics
Within such a broad framework of topics, anyone attempting to find unifying principles for public-health ethics might soon become discouraged. Rules of good conduct are quite easy to define in ethics. Transparency, equity and honesty can be mentioned, as well as other norms that are unanimously accepted in professional and ethical codes.14 However, public-health issues are hard to tackle with simple standards of behaviour: ethical foundations are also required as a basis for decision-making. Until recently, no relevant deontological suggestion or ethical code was available for public-health professionals. One of the most significant proposals of this kind is the American Public Health Association’s public-health code of ethics.15 Apart from in the United States of America, no other wide-ranging efforts have been made to outline codes for public-health ethics. The difficulty of defining the category of public-health professionals has contributed to this gap.
Beside professional codes, other codes and guidelines include general rules of conduct that are relevant for public health. For example, in 2007, David King put forward codes of practice that apply to all scientific circumstances:16Act with skill and care in all scientific work. Maintain up-to-date skills and assist their development in others. Take steps to prevent corrupt practices and professional misconduct. Declare conflicts of interest. Be alert to the ways in which research derives from and affects the work of other people and respect the rights and reputations of others. Ensure that your work is lawful and justified. Minimize and justify any adverse effect your work may have on people, animals and the natural environment. Seek to discuss the issues that science raises for society. Listen to the aspirations and concerns of others. Do not knowingly mislead, or allow others to be misled, about scientific matters. Present and review scientific evidence, theory or interpretation honestly and accurately.Standards for “good conduct” are surely important but rules of good behaviour alone cannot solve complex dilemmas. Conflicts among values often arise in public health, especially among the needs and rights of individuals as opposed to the collective need to protect health as a public asset. In these circumstances, deeper analysis must be performed in the search of principles to serve as reference. Proposals have been made to this aim. The best known document in Europe is that of the British Nuffield Council of Bioethics.17 Wide-ranging comparative surveys have been carried out on the approaches to public-health ethics in Member States of the European Union. Surveys have also been conducted as part of two projects financed by the European Commission including: Basic ethical principles in European bioethics and biolaw (1995–1998)18 and the more recent European Public Health Ethics Network – EuroPHEN (2003–2006).19
Ethical principles for public health
Deontological rules can be applied to different areas, including public health, without much difficulty. However, studies show that greater problems are encountered when moving from the simple behavioural norm to its underlying ethical justification.18,19 Some inputs may be found in the traditional approaches of bioethics but problems do arise.20 Three main difficulties are outlined here in the definition of principles for public-health ethics.
First, one may wonder if the traditional bioethics principles (mainly focused on clinical aspects and on the doctor–patient relationship) can be adapted to public-health ethics or if new directions must be explored to this aim.21,22 The first option is supported by the idea that general ethical principles can be applied, with possible adjustments, to various circumstances.23 It should be noted, however, that environment-specific elements must be considered in implementing these principles.24
Second, the duty to safeguard individual rights must be respected, even if acting within a community perspective that is typical of public health.25
Third, public health has an application-oriented nature and applies to groups or populations. Definitions of public health in the literature clearly highlight its application-based character. According to a very popular definition: “public health is the procedure whereby local, national and international resources are mobilized and committed in order to make sure that people are in a position to live healthily”.26
Bioethicians usually pay attention to the ethical problems of human experimentation more than public-health interventions.27 However, as with research, public-health interventions carry ethical problems. One aspect of these interventions that often undergoes ethical-legal assessment is the protection of personal data.
Public-health research is mainly observational and, as such, does not often raise relevant problems. Nevertheless, public-health interventions involve acting at the individual level and have consequences for equality and justice.1 Moreover, there is a fine dividing line between public-health intervention and research: public-health interventions are almost always research activities in that they contribute to the increase of knowledge.28,29
In this respect, public-health intervention protocols may rightly undergo ethical evaluations on the part of ethics committees and it is not infrequent that the proponents of research want their protocols to be revised by a committee of experts. Still, in most countries, public-health research protocols are not assessed by ethics committees.
Principlism applied to public health
The term “principle” has a broad significance. According to the Encyclopedia of ethics it is defined as “a fundamental rule, law or doctrine, from which other rules or judgments are derived”.30 In bioethics the word “principle” has at least two main meanings, indicating opposite perspectives. The first meaning stands for the foundation of a theory, from which theories derive. The second means practical guideline for action: in this case “principle” derives from ethical theories.31 Often, if not otherwise stated, the term is used to refer to the well-known principles of North American bioethics (autonomy, beneficence, non-maleficence, justice).32
Ever since their formulation, these principles have been widely applied to the ethical analysis of health-care problems, often in conjunction with other principles or divided into subprinciples. Some authors have suggested the application of the principles to public-health ethics.30 However, they have proven inadequate in medical ethics33 and, all the more so, in public-health ethics where conflicts among values arise and value shortcomings are frequent.34 The main problem with the principles is that they often result in relativism. Indeed the principle of benevolence, to do good to others, does not indicate what “good” is and what is right for an individual. Autonomy stands for freedom of action but the concept implies that persons lacking autonomy wouldn’t be considered in certain situations. The concept of justice is similarly ambiguous: the principle does not define what is “just” and to what a person is entitled.
Philosophical theories are also applied to bioethics and public-health ethics. In public health, some positions are more common: positions based on outcomes (utilitarianism), positions focused on rights and opportunities (Kantian theories), views that emphasize sociality and solidarity (communitarianism).1 Utilitarianism asserts that decisions should be judged by their consequences, in particular by their effect on the total sum of individual wellbeing. Following this view, public-health policies must be aimed to produce “the greatest happiness of the greatest number”.35 This approach is very intuitive in public health but has some limitations. Difficulties arise for example in the measurement of wellbeing which can be defined with reference to an individual’s personal experiences or to more objective and measurable components, e.g. quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs).36 However, the most important critique to utilitarianism is grounded on the view that it easily leads to unfairness and to the sacrifice of individual rights and freedoms to warrant the public utility.37 Individual rights and freedoms are the main good to be preserved in Kantian theories. Kant argued that human beings ought to be treated with respect, as ends in themselves, not as means to another individual’s ends.38 This assertion has important consequences in public-health policies, but is not without ambiguities. Indeed two kinds of liberalism can be drawn: libertarians and egalitarians.39 Libertarians believe that only negative rights deserve protection to warrant individual freedom. By contrast, egalitarian liberals argue that the right to choice is meaningless without adequate resources. Respectively, the two perspectives entail a minimal or, vice versa, a strong state intervention for the sake of individual health.
Critics of utilitarianism and liberalism point out that these theories neglect the collective dimension of public-health ethics that is strongly valued in communitarianism. Communitarianism values highly the social dimension of health-care policies and involves visions of the appropriate social order and the virtues that will maintain such an order in a particular community. However, a basic question in communitarianism is: who decides what is virtuous? Every community could define its own norms or, by contrast, a single form of good society may serve as a reference for all communities. Ethics-of-care feminism can also be mentioned. Ethics-of-care proponents argue that real people live in families and real caring relationships are not impartial, impersonal or equal. Health-care policies must hence consider the factual dimension of caring, which is mostly carried out by women, and must be more supportive towards caring roles.39 All the outlined theories in our view may offer a contribution to a continuing discussion about how to deal ethically with public-health matters and how to organize society. What is missing in these theories is a clear definition of the concept and value of the human person: a primary point in personalism.
From traditional philosophy to personalism
Personalism may offer some compensation for the conflicts and shortcomings of principlism. For reasons of comprehensiveness, it might be useful here to mention its most elementary, and possibly obvious, aspects. Personalism should not be confused with individualism, which considers auto-decisions as the main (or only) constitutive feature of person. Personalism is based upon our common shared human nature. It takes as its primary ethical principle that all human beings deserve respect. A human is the only being capable of self-reflection and comprehension of the meaning of life.40
The principles of ontologically- based personalism in bioethics may be summed up as follows:31the defence, intangibility and sacredness of human life; the therapeutic principle whereby any intervention on life is justified only if it has a therapeutic purpose; the freedom and responsibility principle, where freedom recognizes respect for life as its objective limitation; the sociality and subsidiarity principle, consisting of the achievement of common good through individual well-being.Some consider the traditional value of the person as a cumbersome dimension. Hence some modern thinkers focus on the individual but not on the person. Post modern philosophers not only dissolve the concept of person but also that of subject.41 Excessive positions like these are also present in bioethics. Still bioethics, especially when applied to clinical and experimental issues, is generally attentive to the individual person. The problem arises in defining the person and the moment when he/she begins and ends, from the status of the human embryo to the dignity of the dying. Personalism strongly emphasizes the need to protect the weakest and the sickest persons in society. In a personalistic view, the being and dignity of the person are fundamental and inalienable values. Moral actions can thus be measured in respect of the person’s being and dignity.42 This can be stated through a formulation that is similar to the second Kantian imperative: the person “should never be treated as a simple means, as an instrument that can be used for the purpose of achieving any other end: on the contrary, the person should be treated as an end, or – more specifically – respecting, and in some cases promoting, its own ends”.43 In Kant’s philosophy, however, this imperative has a negative connotation.44 Personalism does not simply exclude negative behaviours but requires positive attitudes.
Personalism and its application to public health
When applied to public health, personalistic principles include a set of duties which derive from respect of the person. These include respect of the individual’s autonomy, the safeguard of confidentiality within a collective and potentially de-personifying framework, the effort to guarantee equity and equal opportunities for everyone in the allocation of health-care resources.45,46 Personalism is not opposed to other ethical theories as it can have both points in common and divergences with them. In a personalist view, for example, the consequentialist-utilitarian approach can certainly be part of a public-health policy as long as the lives and well-being of individuals are preserved.47
Respect for individual rights and freedom is also an essential requisite of human coexistence if it comes with regard to the “correct exercising” of freedom that is bonded to respect for life. In public health there might be cases where freedom must be sacrificed to the advantage of the common good. A minimum limit however should never be exceeded and decisions should never heavily penalize a person’s living conditions. If the wellbeing of the community is at stake, personalism does not exclude “moderate patronizing.” Gerald Dworkin defines patronizing as “the interference with a person’s freedom of action for reasons which exclusively refer to the wellbeing, good, happiness, needs, interests or values of a person who is subjected to the coercion”.48 A moderate form of patronizing is justified both in serious or emergency circumstances (such as during epidemics where persons need to be isolated to prevent the spread of a disease), and in routine conditions where the subject may not be in full charge of the situation and hence it becomes necessary to force certain behaviours (such as the compulsory wearing of seatbelts).
Cautionary policies based on the precaution principle are also significant in terms of public-health ethics. When scientific data are contradictory or quantitatively scarce, it is possible to appeal the precautionary principle. This principle shows the need for making temporary decisions that may be modified on the basis of new facts that eventually become known.49
Some authors have singled out the precautionary principle as one fundamental value in public-health ethics, alongside justice, transparency and the choice of the least restrictive alternative for people’s autonomy.50 Special importance has been attached to the precautionary principle by European ethics.51 Its relevance is also underlined by the Italian Committee on Bioethics and the Pontifical Council for Justice and Peace, with reference to the ethics of social and collective problems and to environmental issues.52,53 Personalism strongly values principles of sociality and solidarity. However, the individual’s good is the basis for common good. The social dimension of personalism, which was highly emphasized at the beginning of the 1920s, contributed to the renewal of classical personalism and the foundation of the modern personalism of Emmanuel Mounier and Jacques Maritain.54,55
Personalism proposes firm points to be respected by health-care policies and positively proposes “principles” such as solidarity and subsidiarity to be valued in public-health ethics. Critics of this approach may consider personalism as a theoretical speculation with limited operational relevance. However, we agree with Taboada & Cuddeback that “answering philosophical questions…about the essence and the value of human health, is crucial for the solution of political problems such as how to legislate health care policy”.56
The founding basis of universalism, personalism and solidarity as an anthropological concept is shared, today, by representatives of different cultures.57 If we want to promote development from a health viewpoint, we must move from a solitary, individualistic approach to a personalist approach in an integral sense. Going forward, we must rethink the concept of coexistence in our world, starting from the assumption that we all belong to the human species, with consideration of our different identities and, therefore, shift from the “individual” to the “person.” ■
Competing interests: None declared.
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