O’Neill (2004) provides a strong argument that the ethics of informed consent cannot be extended to public health provisions. The rationale for this argument is that informed consent is a right that can inherently only benefits individual agents, not the health of an agent overall. Cases like the spread of infectious diseases factor importantly in this discussion, because an individual’s decision to forgo certain public health provisions (i.e. vaccination, treatment of the disease) affect the population overall. On O’Neill’s view, informed consent is a moral principle that should guide individual interactions between a doctor and their patients. In this post, I will entertain an alternative hypothesis—that informed consent cannot be abandoned in public health policy. From this, it can be decided if a tenable approach to public health can surface. Ultimately, I conclude that it cannot.
Under a model of public health that does not abandon informed consent, no public health policy would result in a compulsory action. Informed consent, in itself, would be considered a public good, on the same level as the prevention of disease transmission. Public health policies would not be laws in the true sense, but guidelines. A salient example is vaccination. Suppose the legislature of country X passed a vaccination law with the goal of stopping the spread of some disease. For the goal of preserving individual autonomy, the law has a clause which permits individuals to forego vaccination.
We must examine several possible consequences of individuals foregoing vaccination in country X. It is possible that nobody would be vaccinated. In this case, the spread of disease would be a necessary victim to preserve autonomy. A second possibility is that everybody is vaccinated. In this case, both the goal of preserving autonomy and of preventing the spread of disease are met. A third possibility is that some people are vaccinated and some are not. In this case, informed consent is preserved, but the spread of the disease is only partially curtailed.
Among these possibilities, the second and third seem to be desirable public health goals. (Note that, for the sake of this argument, I am not considering compromised herd immunity to be a variable.) But only the second possibility effectively deals with the spread of the disease, and thus the only one that maximizes the public good. If we examine the first and third cases, where some or all of the population chose not to obey the public health provision, we can clearly see that informed consent should not be afforded a privileged position in public health policy.
In the cases of informed consent that we have examined so far, the results of foregoing treatment were at worst detrimental to the individual’s health. But public health is qualitatively different from individual health choices. The goal is not treatment, but prevention. Autonomy in treatment means that the person being treated can, ultimately, make his own decisions. Does it even make sense to speak of autonomy in prevention on a group-level? I doubt that it does. After all, decisions (like foregoing vaccination) do not just have individual consequences, but group-level ones. If we are to posit that public health policies should maintain individual autonomy, we are, in effect, not even making public health decisions.
O’Neill, Onora. 2004. “Informed Consent and Public Health”, Philosophical Transactions: Biological Sciences 359 (1447): 1133-1136.
8 thoughts on “Can we preserve informed consent in public health? No.”
While I agree with the argument that informed consent in public health matters needs to be forgotten for the sake of the public good, I think Jennifer makes an interesting point regarding O’Neil’s presented argument. I additionally believe that her argument can be pushed for public health issues that pertain to the individual over the “group”.
Informed consent in the “legal” paperwork sense does need to be forgotten. However, informed consent in terms of distributing information needs to still be part of the conversation. While a certain public health initiative may be “mandatory”, health officials should still take the time to educate the population on the importance of said initiative for it to truly remain a prevention method.
In terms of the individual health vs. group health, I would like to present the example of liver fluke in Thailand. Liver fluke causes liver cancer that comes from eating “blah-som” or raw fish, a delicacy in a certain part of Isaan, Thailand. In this case, education was used as the best method of prevention because inherently there has to be some autonomy in a public health initiative as the individual still must adhere to the choice – mandatory or not. Liver fluke would in no way create a rapid infectious disease that would spread to other individuals but for the sake of “public health”, education initiatives were started without any informed consent per-se, but were based on allowing individuals to gain all of the information they can to hopefully make the health conscious initiative.
What that long rant comes down to is that:
1) I believe informed consent does at times need to be forgotten for the sake of the public good
2) This does not mean that informed consent, in the matter of information and informed decision making can be forgotten
3) This case still applies to public health issues beyond infectious disease, or cases where one individual can affect that of the greater population.
Liver Fluke: http://www.nytimes.com/2011/04/26/world/asia/26iht-thailand.html?_r=0
I have a question- why is it that in your three possible controlled-variable solutions, the second possibility that is everybody is vaccinated keeps autonomy? While in this case I agree that it solves the issue of total prevention, does that in itself eliminate the issue that would question autonomy in the first place (the disease to be treated)?
I like a last point you make about how informed consent should not be afforded a “privileged position in public health policy”. Health equality is skewed enough as it is by other factors already in society.
I agree that autonomy, out of necessity, should go out the window when it comes down to public health. Public health by definition is looking out for the health of the public. If it can’t do that because autonomy stands in it’s way, then it can’t do it’s job. I seriously doubt that anyone would argue that public health shouldn’t be a concern. So, if it’s a concern, then let the people do their jobs.
If however, autonomy poses a problem that can’t be overstepped (as is does) I think we need to consider the following possibility. Everyone should literally be asked if they want to be vaccinated. There needs to be active effort to make contact with everyone offering them vaccination. If they say no, ok. If they get sick, ok. It’s their fault, they knew the risk. As horrible as it sounds, if they die from the disease to which they refused a vaccination, they knew that was the risk they were taking. All those who accepted the vaccination would be protected. (Yes, this would require that vaccinations be 100% effective) But it’s a possible course of action, that if everyone was actively sought out and offered a vaccination, that it might possibly be ok for people to say no.
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