The Goals of Public Health and the Value of Autonomy

1. The Goals of Public Health and the Value of Autonomy Christian Munthe Department of Philosophy, Göteborg University

2. Health Policy: Traditional Goals and Restrictions • Goals • “Good health” • Classic determinants: life and well-being • What is to count as healthy enough? • Individuals • Populations • Tensions between the health of individuals and populations • Equality • Tension between good and equal health • Restrictions • Safety • Classic determinants: life and well-being • What is to count as too dangerous? • Trade-off of risks againsts chances of achieving goals • Autonomy • Competent adults are never to be coerced • Measures should never go against the personal wants of patients • Who is competent? • Exception: serious threat to third parties: communicable disease

3. The Emergence of Autonomy as a Goal of Health Policies • Health Care • Reproductive medicine • Genetic counselling (prenetal diagnosis, presymptomatic testing). • Resources may be used and patients may be exposed to risks for the sole purpose of helping them to achieve their personal plans. • A health care measure may be successful even if life and well-being is not promoted • A health care measure may be unsuccessful even if life and well-being is promoted • Public Health (in several rich countries): • The goal is to create societal conditions that secure the (equal) ability of people to achive good health. • That is: the goal is to secure that people can freely choose for themselves according to their personal plans whether or not to promote their health. • That is: autonomy is a positive value to be promoted by health policies, not only a restrictive line that may not be crossed.

4. Reasons and Problems • Possible Reasons in Favour • People will choose good health if given the opportunity (autonomy an instrument for promoting life and well-being). • No sharp moral line between respecting and promoting autonomy (consequentialist reasoning for expanding the idea of respecting autonomy into a positive value to be promoted besides other values). • The more of life and well-being is secured, the more important becomes the promotion of people’s autonomy (Rawls’ argument from the priority of liberty: life and well-being an instrument for promoting autonomy). • Problems • Measuring degree of autonomy • Theoretical problem: defining an interpersonal scale • Practical problem: modifying public health monitoring instruments • Trade-offs • Life/well-being – autonomy, Intrapersonal – interpersonal • If autonomy promotions can be traded off against other values, can the restriction to respect autonomy still be rigidly upheld? • Choice of reason partly determines what trade-offs are acceptable. • A battery of ’hard cases’ needed for further thought.

5. Some Interesting Implications • Having the promotion of autonomy as the goal of public health opens up for more of side-stepping of the duty to respect autonomy. • Autonomy restrictions presumably easier to justify on the basis of reasons of autonomy rather than other values. • Smoking in public places: staff is not given the opportunity to choose a smoke-free life if smoking is allowed. This holds even if no one would like to have a smoke-free life and even if tobacco smoke is not harmful enough to third parties to motivate autonomy restrictions according to the classic model. • Whether or not the goal of promoting autonomy should be adopted in all countries depends on what basis it is justified. • Instrumentalist: the connection between autonomy and health may vary considerably between countries, regions, cultures etc. • Rawlsian: a country should adopt promotion of autonomy as a goal of public health only if the general level of health is sufficiently high. • Pluralist consequentialist: depends on what conflicts with other values (life and well-being) will emerge: the trade-off problem.