Applying ethical principles to the medical field has proven complex, as highlighted by James Childress in his writings on the complexities of adhering to respect for personal autonomy.[1] The philosophical discipline of bioethics is not narrowly tied to medicine, but expands to cover medical anthropology, medical sociology, health politics, health economics, research, public health policy, and more.[2] Public health aims at improving the health of the community as a whole, and public health initiatives usually involve preventative measures that prolong life and promote health. Generally, public health policy concerns itself with health based on population-level health analysis. Thus, how do ethical principles change when the policy is focused on net benefit for the community, instead of focusing on individual community members?
Concentration on the group needs and health leads to thinking that often forgets about individual rights, but ethical principles of the individual need to be remembered when applying public health policies. Historically, individual rights are becoming increasingly recognized, and in the medical field, consent is a twentieth-century phenomenon.[3] As medicine increasingly recognizes individual rights, it is a logical extension for public health as a discipline to acknowledge analogous rights.
In bioethics, consent is rooted in the ethical principle of respect for personal autonomy, but this principle is complex and limited in application. Childress in “The Place of Autonomy in Bioethics” presents the scope of applicability of the principle of autonomy in medicine. He argues that first and foremost respect for autonomy of persons differs from people who are not autonomous such as children (unspecified age range) and the insane. Also, respect for autonomy must coincide with other necessary ethical principles such as beneficence and care, and in certain circumstances, ethical principles can outweigh or override one another. Thus, under certain circumstances the principle of respect for personal autonomy may be infringed upon, and specifically, the realm of public health needs to consider if policies made for the benefit of the group reasonably infringe upon the personal autonomy of group members.
This past September, 750 students in Winston-Salem, NC faced suspension after not adhering to state vaccination policies for the Tdap vaccination that protects against tetanus, diphtheria and whooping cough or pertussis.[4] Cases of mandatory vaccinations represent paternalistic interventions where interference with an individual’s liberty may be justified by reasons such as welfare, happiness, values, interests, and needs of the person being coerced. Mandatory vaccination initiatives are public heath measures that override rights of respect for personal autonomy for the sake of containing and preventing infection and disease. In context to this case, paternalism functions off the principle of beneficence. Mandatory vaccinations highlight the conflicts between moral principles, and under these circumstances, I think beneficence overrides each group member’s autonomy. While privacy and confidentiality can still be protected, controlling the spread of disease and preventing illness in community members is a moral call to action for vaccination. While it may be easier to fully respect the autonomy of an individual patient than an entire population, public health policy still should not deprive individuals of their rights without thoughtful consideration. Following Childress’s logic, are all group members considered equally autonomous thus infringement upon personal autonomy is the same? Or, based on group status does infringement on personal autonomy have different implications? In modern times, awareness of personal rights is increasing within bounds; therefore, it is important for public health to grasp and debate these ethical concerns. A new interpretation could view mandatory consent as a prior consent based on group membership, and thus interference is the price of group membership.[5] Such a viewpoint believes that the individual’s interests are still considered, but an individual is accepting his or her role as a group member. Future public health policies could work to understand the line between respect for personal autonomy and social responsibility, and from there, public health can define its realm of action and control.
[1] Childress, J. F. “The Place of Autonomy in Bioethics”
[2] Benatar, D. Bioethics and health and human rights: a critical view. Journal of Medical Ethics. 2006 January; 32(1): 17-20. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563274/
[3] Veatch, R. M. “Abandoning Informed Consent”
[4] http://www.journalnow.com/news/local/article_b770c0ca-2484-11e3-93a9-001a4bcf6878.html
[5] Hall, Spencer. Should public health respect autonomy? Journal of Medical Ethics. 1992. 18: 197-201.
You make an interesting point about how the person already gives consent on mandatory procedures simply by being part of a community. Humans are very social and need to work in groups in order to achieve their own autonomic goals. But which is more important, altruism or egoism? In the instance of vaccines, the point of widespread vaccination is to prevent as many people from contracting the disease as possible. One altruistic result is that the more people that are immune to the disease, the less likely the disease will spread across the population. The egotistic result is that you don’t get the disease as well . However, one other benefit from this is that people who decline to be vaccinated benefit from “herd immunity.” Since everyone else is immune, the disease is no longer present in the population and thus cannot spread to those who aren’t immune as well. This is how the eradication of smallpox came about and how polio is also expected to be eradicated. In this case, both public health and personal autonomy are both respected.
You have raised a very interesting point about individual interests as a group member when it comes to autonomy. Time and time again, we have seen court cases where individuals have gone far enough to question or even fight for their rights to be able to carry out certain actions based on personal autonomy. Once such example was Roe v. Wade in which Roe a pregnant single woman challenged the constitutionality of the abortion laws, which prohibit an abortion except in life threatening medical conditions. Such decisions impact society as a whole; Row v. Wade changed many aspects of society most importantly the outlook of sexual activity outside procreation realm. However, even after the Supreme Court decision to legalize abortion, the process has not been normalized within mainstream society. I believe that public health policies understand the fine line between personal autonomy and social responsibility. An individual’s decision might be for his/ her benefits, but its consequences may, impact society as whole. I believe that certain gray areas still have to be considered on case by case basis especially ethical issues which cannot be simply cut-and dried. The end result, however, should be a balance between the two.
I liked the point you raised about autonomy and paternalism in terms of vaccinations. I had never realized or considered this a lack of autonomy. I always thought of vaccinations of simply something that everyone HAD to have. To enter kindergarten, at least where I am from, you need to have certain vaccinations and immunizations. If you do not have such medical treatment, you are denied enter into public kindergarten. This is the beginning of where our autonomy is taken and paternalism is put in place. Furthermore, the long term consequences of this paternalism are drastic. If you don’t want to give your child the vaccinations for whatever reason, they are denied access to public education. Lets say that you cannot afford private education. Now because of your choice, your child is unable to receive an education, People might say well they can still have their education, they just need to get the vaccination. Once again, paternalism is at hand. So are we ever truly autonomous or are most of our decisions just stemming from paternalistic views?
Simone raised a good point about vaccination and education. There is definitely some autonomy taken away from people when it comes to vaccination. Historically, there have been instances where an individual’s autonomy was taken away for the public good. Typhoid Mary was forcibly quarantined for almost three decades because public health officials claimed she was a health hazard to the public. Disregarding the fact that there were controversies surrounding her case, was it moral for the government to do that to one individual? Mary had no say; she was denied freedom for the rest of her life. However, had she remained a cook, she could have infected even more individuals. Paternalism is one of the driving forces of public health. The goal is to protect the public, which most people can benefit from. I think the question is whether beneficence overrules autonomy. Personal autonomy is important but is it still important when it harms others?
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