Utilitarian calculations guide public health as a rational effort to maximize the net wellbeing of the population. Utilitarian measures promise effectiveness, action, and widespread applicability. However, in our society, even the most promising or rational utilitarian measures will be blasted as soon as it endangers  the core American value of individual liberty.

The Model State Emergency Health Powers Act (MSEHPA) for example, was blasted as an attack on individual freedoms by many critics. MSEHPA was a proposal meant to help state governments reform outdated and inadequate public health policies and infrastructure after 2001. It proposed giving states the legal right to ignore certain individual liberties in emergency situations in the interest of public safety. This included permitting public health authorities to physically examine, test, vaccinate, treat, and quarantine individuals as necessary “to prevent or limit the transmission of a contagious disease.” Additionally, authorities would have the right to destroy any facilities or property that posed a public health threat due to contamination. 

Lawrence Gostin, a leading author of the MSEHPA proposal, responded by stating that “in a country so tied to rights rhetoric on both sides of the political spectrum, any proposal that has the appearance of strengthening governmental authority was bound to travel in tumultuous political waters.”

The MSEHPA does propose a breech of personal liberties, and these powers are supposed to  be reserved for emergency situations only. But there’s still no denying that it is a part of a post-9/11 reaction that has gained security at the cost of individual freedoms. The consequences of this reaction are only beginning to resurface as we examine the NSA’s abuse of the Patriot Act. Americans have witnessed how easily power can be abused by the bureaucrats we have entrusted.

Governmental mandates and heightened legal power will always come with a backlash.  What does this mean for public health, and vaccinations in particular? That a mandatory vaccination policy would  be extremely controversial – even to those who believe that it’s the right thing to do. Forget vaccinations. We could be talking about some magical miracle potion here. The fact remains that there’s something justly frightening to the American people about giving the government the power to inject substances into anyone and everyone. As someone who generally agrees that all adults and children should be vaccinated, I believe this direct conflict between utilitarian aims and individual liberty means that we have a duty to raise awareness and incentivize vaccinations without resorting to government mandates.

References

Gostin, L.O. “Public Health Law in an Age of Terrorism: Rethinking Individual Rights and Common Goods.” Arguing About Bioethics. London: Routledge, 2012. 374-384. Print.

Gostin, Lawrence O. “Model State Emergency Health Powers Act: Public Health and Civil Liberties in a Time of Terrorism, The.” Health Matrix 13 (2003): 3.

In Arguing About Bioethics, L.O. Gostin argues that, in terms of public health, government laws take precedence over people’s individual liberties in the event of a “public health emergency” (Gostin 377). He defines a public health emergency as an “occurrence of imminent threat of an illness or health condition caused by bioterrorism or a novel or previously controlled or eradicated infectious agent or biological toxin” (377). The health threat also causes many people to have major disabilities or even die. However, why should we let an emergency happen? Aren’t there steps that we can take in order to avoid the possibility of emergency as best as we can? While preventative medicine is definitely an admirable option, we can take even smaller steps and put public health into our own hands by altering our health habits and behaviors.

The concept of public health emergencies made me think of the movie, Contagion (here is the movie trailer: https://www.youtube.com/watch?v=4sYSyuuLk5g). In this movie, a lethal virus spreads extremely quickly and, soon enough, becomes a pandemic. The virus spreads so rapidly because people do not wash their hands, people touch their faces so many times per day, people don’t cover their mouths when they sneeze, and don’t participate in other sanitary behaviors. Everywhere we go we touch something that someone else has touched and we do not know if that person is sick or not. So, from this movie, we realize that people need to take responsibility for their health behaviors to protect themselves and the public.

While there are laws that override people’s individual liberties in a public health emergency, there are no laws that demand people to wash their hands or not touch their face. Obviously, there never will be. However, in order to avoid a public health emergency, we should focus not only on preventative medicine like vaccines, but alterations of our personal health habits and behaviors. Though we may believe that our personal health behaviors simply benefit us, we are actually benefitting the rest of the public. When a person gets sick, it is very likely that his or her family member or friend will get sick too. People touch the same things and live in close quarters so it is very likely that a virus can be transmitted. Therefore, people need to be responsible and take care of themselves because it is healthy for them and the rest of the public.

Though we may view health in terms of “public health,” it is very important that we do not undermine the power of the individual’s own choices. Again, there will never be laws that demand washing your hands every time we go to the bathroom. But, we should take into account that the doorknob of the bathroom will not have as many germs on it because we washed our hands, so then other people will not get our germs. Small decisions can prevent large outcomes that we would want to avoid. Therefore, rather than focusing on the preparation for a public health emergency, or even focusing on preventative medicine, we should focus on our behaviors that will increase the likelihood that we will stay healthy.

Works Cited

Gostin, L.O. “Public Health Law in an Age of Terrorism: Rethinking Individual Rights
and Common Goods.” Arguing about bioethics. London: Routledge, 2012. 374-
384. Print.

L.O Gostin is justified in saying that the current public health laws have two very important issues that need to be changed. I believe that these changes need to be made in order to offer all patients and even health care providers with their autonomy and a fair and just healthcare experience. The two changes Gostin suggested include adjusting the low amount of power that is not able to deal with the many health threats and risks. Also, Gostin suggests having clear rules and fair procedures to make decisions.

It is difficult to implement changes in the realm of health if the amount of power given is not adequate. Another question to consider is who should be given the power? Gostin discusses the division between state and law. The state holds more power in the realm of public health because public health issues can vary between states. The state tends to hold more power also because many of the powers that are required for public health legislation, such as police, inspection, quarantine etc. are already held by state officials and can differ drastically between states. Regardless of this, however, the federal government also has power in public health; for example the response to health risks that can affect many states at a time. This discussion in amount of power required for public health decisions can also be compared to public health issues in hospitals. The powerful debate lies between the importance of personal libertarianism versus the health of the public and the community.

Recently at Princeton University, there was an outbreak of meningitis B which has caused the death of some students. In fact, a student from Drexel who was in close contact with Princeton students died after being ill for approximately one week. To prevent the spread of this deadly meningitis disease, a high percentage of Princeton students were given a meningitis vaccine. This vaccine, however is not approved for use in the United States. The CDC and the FDA did allow the drug to be used. Through two doses of the vaccine will most likely protect the patient, the patient may still be able to spread the disease through close contact with others.

Considering the two issues that Gostin points out in his discussion of public health, one can question the morality in the decision of the CDC and FDA to make some students take the unlicensed vaccine. Was it the right decision? Was their level of power used in this situation used correctly? Did the students have a right to choose to take the vaccine or not? Such questions demonstrate that the amount of power given by some institutions is extremely confusing with regards to public health. There is ambiguity in the amount of power the FDA and CDC have, and the amount of autonomy the students SHOULD have. Did the students know this vaccine was not a drug that was approved for use in the US? The fact that this drug was only approved in 3 countries—Canada, Australia, and Europe, show that there are some risks of this drug that US health administrations were still discussing.

As Gostin pointed out, another issue is that public health statues do not give clear standards or indicate how decisions should be approached to ensure they are fair. Was it fair to give a vaccine that was not approved for US use, in the hopes of preventing other deaths, but simultaneously risking the infection of other students and also risking the life of the person receiving the vaccine? Has this happened before, and were the same decisions made? Will it happen again, and the same decision will be made? Probably not, because each situation varies so that different questions need to be asked and different ideas and issues need to be discussed. As Gostin indicates, these issues cause public health laws to be difficult to understand and difficult to implement.

Gostin, L.O. “Public Health Law in an age of terrorism: rethinking individual rights and common goods.” Arguing About Bioethics. By Stephen Holland. London: Routledge, 2012. 374-385.

Hayes, Ashley. “Philadelphia meningitis death tied to Princeton outbreak.” CNN 18 Mar. 2014 [Philadelphia] . Web. 22 Mar. 2014.

“Preventive care carries a quasi-moralistic message that people and societies are responsible for their health and must shoulder certain disciplines in order to avoid disease” (Brody and Englehardt 299).  The idea of preventive medicine makes an individual in charge of his/her own health by preventing disease or illness before it ever occurs. Preventive care encourages a sense of responsibility in people by letting them take direct control of their own health. It promotes the idea that, avoiding bad things from happening is better than fixing the bad things after it happens. If bad things still occur, it, indirectly, holds an individual and society accountable for letting it happen at the first place.  However, as Brody & Englehardt say that since preventive care is not clearly medical, (prevention happens before medical intervention) it does not fall within the jurisdiction of influential scientific organizations. Moreover, scientific organizations emphasis more on statistics which makes it easy for them to report their findings and hence more resources are allocated to their programs.

According to Brody and Englehardt, many countries allocate money for fixing health problems as they occur rather than allocating it towards increasing resources so that these health problems can be avoided.  These countries’ healthcare system focuses on reactive medicine in which the symptoms are treated as they occur rather than working to prevent them from getting happening in the first place. Both culture and medicine in these countries have formed a relationship which is acceptable for the majority of their population.  It is difficult for these countries to ever come out of this cycle because it is much easier for them to report quantifiable findings for the cure of the sick. On the other hand, it could be not only difficult, but nearly impossible to quantify actions which may or may not prevent an illness. For this reason, even though, the benefits of preventive medicine are clear, they are not definitely measureable which makes it a less popular approach.

I believe that the global differences in medical practice, that Brody and Englehardt talk about, will continue to differ, until a joint consent is made to align them. Some of these countries are among the poorer nations where the governments constantly face a vicious cycle of disease and poverty. These places are in a need of the competencies and incentives so that their strategy can be shifted from reactive methodology to proactive mode of care.  Furthermore, an approach a country takes towards preventive health care is greatly influenced by their culture where each believes in their own practice method as being the best. For example, in the U.S, risk reducing mastectomies are patients’ choice and can be carried out for carriers of the BRCA mutation gene to prevent the risk of developing breast cancer. However, France only favors mastectomy if the risk factor is greater than 60% and that only if a woman is at least thirty years old (Payer 183). This is largely due to their perception of preventive mastectomy as a tragedy and not a celebration of an improved life.  It is therefore important to identify a bio cultural approach of healthcare, one that defines health in both biological and cultural methods, explaining how disease and societies are integrated. This way of understanding takes both societal, traditional views and perception of disease, and the way the diseases and illnesses are best cured using traditional and or biomedical healing.  By understanding this bio cultural approach, we can appreciate the benefits each have to offer and possibly use these benefits to better our and other health systems around the world.  With all said, what Brody and Englehardt refers to cannot be denied that, every individual and every society still needs to consider health in a moral sense and adopt self-control behaviors in order to avoid future health problems.

Work Cited

Brody, Baruch A. Bioethics: readings & cases. Englewoods Cliffs, N.J.: Prentice-Hall, 1987. Print.

Payer, Lynn. Medicine & culture: varieties of treatment in the United States, England, West Germany, and France. New York: H. Holt, 1988. Print.

34 countries make up the OECD (Organisation for Economic Co-operation and Development) a group of countries dedicated to global development, almost all of which have a high Human Development Index and are high-income economies. Of these countries Mexico, Chile, and the US are the only countries where less than half of spending on healthcare is publicly financed (OECD).

Green represents countries with universal healthcare; grey represents countries without universal healthcare (Fisher)

Mexico and Chile have two of the lowest three GDPpc (gross domestic product per capita) adjusted for purchasing power in the OECD with $17,019 and $21,486 respectively (OECD). The US is clearly an outlier being one of the only developed countries without universal healthcare and by far the richest without it. It is well within the ability of the United States to provide universal healthcare. People can argue about the economic pros and cons of universal healthcare, but at its core, the lack of healthcare provided to everyone in the US is a moral issue. “While other countries have declared health care to be a basic right, the United States treats health care as a privilege, only available to those who can afford it” (Chua).

According to Lawrence Gostin, a government “is compelled by its role as the elected representative of the community to act affirmatively to promote the health of the people” yet “cannot unduly invade individuals’ rights in the name of the communal good” (11). This seems paradoxical, but a government must consider whether the benefits of promoting the health of its people outweigh and justify the invasion of the individuals’ rights. Considering the wealth of the US (GDPpc = $51,689), the impact on each individual would be relatively little with a small portion of people’s paychecks being diverted specifically for healthcare as opposed to the more generic taxes where it is not immediately clear where the funds are going. And the impact would be dramatic. Every year 18,000 excess deaths occur among the uninsured under the age of 65 (Institute of Medicine) and many more live with aliments that could be relatively easily treated or crippling debt due to necessary healthcare costs. The problems from the United States’ lack of universal healthcare falls, like many societal harms, disproportionally on minority groups. Hispanics are two to three times more likely to be uninsured than non-Hispanic whites (Institute of Medicine). Viewing healthcare as a privileged also perpetuated the cycle of poverty which so many Americans are trapped in.

The United States has a moral obligation to provide universal healthcare to its citizens. There is “No ethical principle can eliminate the fact that individual interests must sometimes yield to collective needs” (Childress) and the case of universal healthcare is a time where the rights of the individuals must be infringed upon in order to provide for the general population.

Work Cited

Childress, James E. “Public Health Ethics: Mapping the Terrain.” Journal of Law, Medicine & Ethics (2002): 170-178.

Chua, Kao-Ping. “The Case for Universal Health Care.” 2005. American Medical Student Association. 16 March 2014.

Fisher, Max. Here’s a Map of the Countries That Provide Universal Health Care (America’s Still Not on It). 28 June 2012. 16 March 2014.

Gostin, Lawrence. Public Health Law: Power, Duty, Restaint. University of California Press, 2008.

Institute of Medicine. Care Without Coverage: Too Little, Too Late. National Academies Press, 2002.

OECD. “Gross Domestic Product.” 2013. OECD. 16 March 2014.

OECD. “OECD Health Data 2013: How does the United States Compare.” 2013. OECD. 16 March 2014.

How should we make decisions in public health and who should be held responsible? Is it the individual or the society who is responsible for own their health? A person is responsible for their health to a certain extent. The doctor can only tell you so much and supply you with resources to aid you in the process. For example, if someone has a smoking habit, and they’re health is in cardiovascular danger. If the doctor has given them sources to help them, but they are not receptive to the treatment then they should be held responsible. Our society is made up of individuals, some who take care of their health and some who don’t. Public health focuses on the society as a whole.

One of the main issues in public health is that they are trying to fix issues quickly and directly. Sometimes in our society we wait on things to get bad, and then we want to fix it instead of increasing primary prevention. For example, “How can you expect me to be healthy if I can’t afford it?”. According to the Brody and Englehardt article, some third world countries are misguided in that they allot more financial aid for improving health as opposed to allocating money to the accumulation of the capitol. In my opinion, when money is given to the health fund, it is a more direct approach, but sometimes a different strategy is needed. As stated in the article, setting money aside for the capitol will help people get jobs and more money, which will increase health. This is a more indirect approach and may take a longer time to be effective, but I feel as though in the long run this may be the most impactful approach.

However, one can never be too sure on which approach to take, because some situations call for different approaches. Although, when one approach fails, the government should try to switch to an alternate method. The best method should be to attack the issues before they even fully develop into major problems. This method may seem unrealistic for issues that are unforeseeable and may contribute unforeseeable consequences. However, even if an issue is just beginning something can still be done to prevent the particular issue getting worse. For example in the article by Brody and Englehardt, it is stated that we would rather spend $100,000 on rescuing people from a trapped mine as opposed to investing in mine safety. Instead of letting a mine get to the point where it collapses, we should set money aside to help the damages in the mine before it gets out of hand.

When trying to fix the issues we also must think about who’s in power to fix these issues. The government has most of the power of where to distribute funds. They are the ones that decide which type of approach should be taken.  According to the WHO website, there are 4 steps that need to be done to properly execute the public health approach: 1) Surveillance 2) Identify risk and protective factors 3) Develop and evaluate interventions 4) Implementation. These are good guidelines to follow, but we must be sure to execute each step in a cost effective and timely manner.

 REFERENCES

Brody and Engelhard. “Preventative Medicine,” Bioethics: Readings and Cases

http://www.who.int/violenceprevention/approach/public_health/en/

http://healthyamericans.org/public-health-funding/

It has long been questioned whether preventative medicine should be required. Some limitations to preventive medicine include lack of funds and lack of individual compliance. In reference to the lack of funds, many countries lack the finances to provide adequate prevention for any number of diseases and often have to decide between providing prevention and treating diseases. Often, these countries decide to provide the best care for the most people. The lack of compliance issue is usually more of a problem in developed countries where parents don’t want to subject their young children to things such as vaccinations that can cause severe health issues. This is immoral because these parents are presenting their children to a disease that is more likely to cause harm to their children than the possible side effects of the vaccine. I believe that everyone should be vaccinated for diseases that have been eradicated from the US or that are close to being eradicated.

A recent example for why routine vaccinations should be required can be seen in the recent measles outbreak in New York. Within the last month or two, there has been a measles outbreak in New York City. There have been at least 19 confirmed cases of measles. In 2000, measles was considered to be eliminated from the US. Between 2000 and 2013, an estimated 63 cases were found each year, mostly from those traveling abroad. Since 2013, the number of cases have tripled due to the number of people being vaccinated having dropped to only about 90 percent.

There are severe complications accompanied with measles, so most individuals are vaccinated. However there are some who refuse to vaccinate their children due to the rare risks associated with the vaccine. The public health question now is should everyone be required to be vaccinated for measles in order to protect the health of the population? I believe that, for the good of the population, everyone should be vaccinated and up to date on all their vaccinations to protect those around them. By requiring this, almost every individual will be vaccinated and will provide herd immunity to the select few who are not. I believe that there is a huge difference between those who do not want to be vaccinated and those who cannot be vaccinated due to other health related issues.

For those who have not been vaccinated, the reason usually stems from the desire to not be subjected to the potential risks associated with the vaccine. These people are called “free riders”. In my opinion, the decision to not vaccinate is immoral as these individuals put the rest of the public in harms way. Some may argue that vaccinations cost too much for certain classes of people in the US. However, the price of vaccination versus the cost of treatment shows that by not vaccinating, people are actually going to end up spending a great deal more for treating the disease. As Brody and Engelhard stated in their essay, ‘preventative medicine and public health measures have traditionally been a part of medicine.’ This statement is very real and true. We, as an individual and as a nation, have a responsibility to protect those around us from disease due to the lack of vaccination.

http://www.cdc.gov/measles/outbreaks.html

http://www.slate.com/articles/health_and_science/explainer/2014/03/measles_outbreak_in_new_york_should_people_get_revaccinated.html

Brody and Engelhard. “Preventative Medicine,” Bioethics: Readings and Cases

Preventive medicine is a branch of preemptive healthcare that focuses on the protection, prevention, and maintenance of well being in order to prevent disease, disability, and death. The way in which individuals think about health has changed drastically over the years, as research leads individuals to believe that they have a great deal of control over their health-related future. Preventive medicine has been given more attention in recent years, in an effort to combine new medical knowledge and advanced technology to decrease the incidence of disease and mortality. While preventive care can be extremely beneficial in reducing such high rates of disease and death, such intervention is often expensive and particularly controversial. In their work Preventive Medicine, Brody and Engelhard illustrate several cases that show the controversial nature of preventive care. Two specific cases addressed highlight preventive care conflicting with expenses and personal choice.

Case A: The central question in this case is how often pap smears should be given to women. While literature suggests that every 3 years is sufficient, clearly, a yearly test would be even more proactive in preventative care for women.  The clinic must decide if it is worth the 50,000-dollar difference to give yearly pap smears, as opposed to one every three years.

Case B: This case deals with preventive care in the form of a vaccination. A mother does not want her baby to get DPT vaccinations because of the potential side effects, such as mortality due to whopping cough. The mother is relying on the idea of herd immunity, however, this concept won’t hold true if more and more mothers become “free riders”.

Both of these cases address sacrifices that must be made in public health. In Case A, money can be sacrificed for greater prevention, whereas in Case B, personal values and autonomy can be sacrificed for a public good. While there is no “clear” right answer to either of the above scenarios, these types of decisions are made on a daily basis in the realm of public health.

In her op-ed article “My Medical Choice”, Angelina Jolie details her reasoning for getting a preventive double mastectomy this past year. Genetic testing showed that Jolie had the BRCA gene, a gene that increases a woman’s chance of developing breast and ovarian cancer. Jolie was told that she had an 87% risk of breast cancer, and a 50% risk of ovarian cancer. Fortunate enough to have the knowledge and the financial means necessary to undergo surgery, Jolie had the preventive surgery and her chances of developing cancer have decreased drastically.  Jolie states, “It has got to be a priority to ensure that more women can access gene testing and lifesaving preventive treatment, whatever their means and background, wherever they live.”

Preventive care is a crucial component of modern day health care as it expands individuals’ options. However, there are significant financial and moral costs involved in this type of care. For example, in reference to case A, giving pap smears more frequently may result in higher prevention of cancer, and in turn, less incidence of disease and mortality. However, giving pap smears more frequently may also result in a greater likelihood of misreading test results, causing patients needless worry and operations. Thus, it is important for patients to be fully informed in order to make their own decisions regarding medical treatment. While preventive care should be available to all, the facts and the risks associated with such care must be clearly understood in order for individuals to confidently make medical decisions.

Works Cited

Brody, Baruch and Englehardt, Tristam. “Preventative Medicine.” Bioethics: Readings and Cases. Upper Saddle River: Prentice-Hall, 1987. 298-301. Print.

Jolie, Angelina. “My Medical Choice .” New York Times 14 May 2013: n. pag. My Medical Choice by Angelina Jolie-NYTimes.com. Web. 14 Mar. 2014.

A simple test will determine if a person will die of a medical cause within a 5 years period. A study found that high levels of four different molecules in the body: albumin, alpha-1-acid glycoprotein, citrate and very low-density lipoprotein particles, predicts death within a certain time. Researchers still have to find out how these 4 biomarkers are associated with the risk of death.

 http://fox2now.com/2014/03/10/test-may-some-day-predict-5-year-risk-of-death/

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.