Informed Compulsion

O’Neill (2004) takes on a somewhat utilitarian view of informed consent in light of public health issues, essentially arguing that when public health provisions are for the benefit of the greater good they should be compulsory:

“It has come to seem controversial on the basis of an illusory assumption that all medical provision, and with it public health provision, can be organized on the basis of informed consent of individuals. It cannot” (1136).

This is a reasonable proposition. It seems that if an action is necessary on the part of individuals in order to protect the population at large, it should indeed be considered the correct course of action for each individual to take, regardless of their personal beliefs or convictions. Take for example vaccinations. When parents fail to vaccinate a child, they put that child (and her peers) at risk for the unnecessary contraction of a disease. If all children in a community are vaccinated, the community at large is safer, healthier.

However, O’Neill devalues informed consent to too great a degree in his claim that “an adequate ethics of public health needs to set aside debates about informed consent and to consider the permissible units of just compulsion for various types of public good.” For while informed consent does indeed deal with the autonomy of individuals, O’Neill disregards a significant portion of the concept — the “informed” part of “informed consent.” Informed consent  (in most cases) doesn’t necessarily mean that an individual is irrevocably free to say yes or no to a procedure regardless of consequence; rather, it represents an individual’s right to be educated about a procedure they are going to undergo or a medicine they are prescribed. In the case of public health, this aspect of informed consent is no less important than it would be on an individual basis.

In this way, compulsory actions taken in the name of public health should still be under the scrutiny of bioethical debate. While it may hypothetically be ethical to make some action compulsory in the name of public health, the manner in which this is done is still important. In the case of the vaccination example, explaining to parents clearly and concisely why their children should be vaccinated, whether this be at the doctor’s office face to face or in the form of a pamphlet or television program, is a way of respecting the autonomous nature of the individuals at large — the parents and their child — while still acting in the name of the greater good.

In her article, O’Neill makes compulsion seem much more cut-and-dry than it truly could ever be. A mass public health movement meant to benefit an entire population still affects the lives of individuals. Accordingly, the needs and wants of the individuals cannot be completely ignored and their concerns must be answered, whether or not they are given their way in the long run. O’Neill confuses the right of informed consent with complete unhindered freedom and therefore misconstrues the details of what a compulsory public health initiative would truly entail.

O’Neill, Onora. “Informed consent and public health.” Philosophical Transactions of the Royal Society of London. Series B: Biological Sciences359.1447 (2004): 1133-1136.

5 thoughts on “Informed Compulsion

  1. I completely agree with you- O’Neill is completely wrong in assuming that all individuals should naturally make the decision that benefits the greater good. Perhaps the parent feels compulsion to keep needles and medicine away from their child, for the child’s own good. When a parent considers vaccinating their child, I’m sure the last thing that comes to mind is the benefits that other children will receive… O’Neill would probably say this way of thinking is selfish, but when considering public health initiatives, we must not ignore the rights and concerns of individuals. Instead of criticizing parents that don’t like vaccines, we should provide information to them. We should explain how the autism study was completely flawed and the researcher who wrote the study was forced to end his career as a doctor due to his professional dishonesty. The CDC probably has the most reliable/factual information. This web page includes reasons why we should vaccinate our children: The CDC explains how the individual child will be protected from an illness, as well as contributing to the greater good by helping diseases become rare or even eliminated. They even cite an example of vaccines working in Japan for whooping cough, until a certain rumor spread that scared people away from the vaccine- soon after, a whooping cough epidemic occurred.

    Centers for Disease Control, Vaccines and Immunizations. (2012). Why Immunize? Retrieved from:

  2. Considering the idea of making vaccines compulsory makes me wonder how much it would actually change. It would be interesting to know exactly how many children born in hospitals go un-vaccinated. I would assume that the vast majority of do get their vaccinations. For those that do not, they may continue to refuse them even with the implementation of a compulsory vaccination policy. I think that it is unrealistic to think that a law would make much of a difference for the health of the greater good. The issues it would cause in the form of civil liberty suits would do more harm then good, and in the end I think that trying to make vaccination compulsory would fail. In the end, people are going to have their own beliefs and do what they want. Not having vaccinations can keep them from participating in certain public events and services, but it won’t prevent them from living in society. The best that the healthcare system can do is to try and inform and persuade people as best they can of the importance of being vaccinated and hope that they make the right decision for the greater good.

  3. To go off of the example of child vaccinations, I do agree that physicians and medical personal should educate parents about vaccinations. They should illustrate on the pros and cons of vaccination and provide adequate, true information about the process. This will increase the patient’s autonomy because they are basing their beliefs off true information. If they decide against vaccination based on the fact that they don’t want to risk the cons then that is fine. However if they base their decision off irrational beliefs (ie vaccinations cause autism) then they are not autonomous and physicians should paternalistically protect them against their will. Overriding a parent’s decision that is based off of irrational beliefs, will also promote the general public, not just the child. In the case where the decision is based off rational beliefs (cons of the vaccination) then it is best to respect the parent’s autonomy. While this does expose their child to potential disease, it wont effect the general population to a large extent. Assuming that most of the public gets immunized, the herd immunity of the population will protect that particular individual.

  4. I appreciated your main point revealing the novelty of his argument- the concept of the “informed” part of “informed consent.” While it is very agreeable that things that benefit the greater good should be compulsory, the value of informed individuals, I think, although slightly brought up here, is often swept under the rug. Does it matter that people know what they are given for the greater good of the community? My answer is yes, with the story in a book commonly assigned in middle school called “The Giver” by Lois Lowry in mind. Informed people would prevent abuse of power that could happen in certain communities by health officials, no matter how well meaning.

  5. As your post and comments show, I also agree that O’neil takes the compulsory notion too far. As there is an increasing focus on individual rights in the practice of medicine, I believe that there needs to be a parallel greater focus on individual rights in public health also. Georgia in the above comments brings up an interesting case of the story in the novel “The Giver,” and I believe the issue of informed consent needs to be brought to public health in the form of education. This issue becomes complex though because I do agree with O’neil in the necessity of such public health interventions such as vaccinations. Thus, an education component could inform society members about why they need to get these vaccines or etc.

    Or, another way to transform the compulsory argument beyond what O’neil presented would be to make these public health measures a requirement for membership to society. Again the issue as presented in “The Giver” arises, but this is where the ethics or specifically a utilitarian viewpoint could point to the net benefit for society for a policy of vaccinations for membership.

    Bottom line, I think the compulsory argument walks a dangerous line. But there are also deadly dangers to anti-vaccine campaigns. A utilitarian model could be a way of evaluating these net benefits vs. net costs. A central debate to this model would revolve around the differing values of the individual and society as a whole.

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