A role for moral vision in public health.
|Author:||Rubin, Daniel B.|
|Publication:||Name: The Hastings Center Report Publisher: Hastings Center Audience: Academic; Professional Format: Magazine/Journal Subject: Biological sciences; Health Copyright: COPYRIGHT 2010 Hastings Center ISSN: 0093-0334|
|Issue:||Date: Nov-Dec, 2010 Source Volume: 40 Source Issue: 6|
|Topic:||Event Code: 290 Public affairs Advertising Code: 91 Ethics|
|Product:||Product Code: 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs|
Bioethics and public health are largely estranged. Questions of
moral and political philosophy are relevant to the means and ends of
public health, but often go unasked. Population-level concerns are of
mounting importance for bioethics. Greater engagement between bioethics
and public health would yield benefits for both fields.
Public health rests on assumptions about what it means to live a good life. The concepts of health and well-being are a matter of values as well as of fact; they are informed by considerations about what makes life worth living. Similarly, the degree to which the state should intrude on personal liberty to improve public health hinges on the scope of individual autonomy. Critical examination of these claims would help public health practitioners balance competing values and assumptions. Such engagement should consider not only the effect of public health on the moral dimensions of individual health, but also the complex web of relationships that are social determinants of health. At the same time, greater engagement with public health would help bioethics grow as a field; bioethics would develop new competencies and modes of thinking, which would in turn shed light on other population-level issues.
Greater engagement between bioethicists and public health researchers and practitioners could lead to more open discussions of the role that values can and should play in shaping public health policy and informing public health practice. This would be very helpful for the field of public health. On a practical level, values are relevant to public health because individuals' values affect health-related behaviors and thus are themselves issues in public health interventions. Individuals' values may prove to be an impediment for health interventions, but also may be a tool for change.
A critical examination of public health's norms would compel the field to reflect on the way that values inform its activities and to confront the mixed legacy of its early history. The norms operative in public health are often obscure because the underlying questions go unexamined. Ignoring the vital role that values play in shaping current public health policy invites the same hubristic tendencies that once coopted public health and used it for forced sterilization, eugenics, and other forms of "social hygiene." If public health is to be intellectually honest, it must evaluate norms critically and examine how, historically, it has interacted with and been shaped by social values and political beliefs.
The most fundamental and compelling reason for public health to develop its moral vision through engagement with bioethics is that the methods and ultimate goals of public health are, at least in part, contingent on the question of what it means to lead a good life. While public health interventions were once accomplished through improvements to infrastructure--for example, through better sanitation and clean water--today public health goals often require changing individual behavior, often through state action. Such interventions raise substantive questions about the extent to which government, in a democracy, should intrude on individual bodies to improve the health of the body politic. While others have discussed similar concerns under the rubric of health and human rights or "public health ethics," these areas of study have only been ancillary outgrowths of bioethics. I think a more integral incorporation of these concerns is needed. These questions are not merely academic or philosophical--ask anyone who has been questioned, isolated, quarantined, or inoculated by the state against his or her will. Questions about what the state may do and how far it may go to achieve public health outcomes are also pressing to legislators, regulators, and lawyers. Finally, they are of deep political relevance to all who are committed to the values of an open and democratic society.
While fundamental values underlie public health practice, they also inform the goals of public health policy. What it means for an individual to be healthy and well is as much a question of the nature of human flourishing as of physiological functioning. When should we privilege mortality over morbidity? Should we measure a quality-adjusted life year, and if so, how? What about subsidizing "wellness" interventions with tax dollars? These questions can be answered only by integrating bioethics and public health.
Questions about the nature and meaning of individual health become even more complex when individual health is viewed in its social context. Social and demographic factors are strong determinants of health status. Likewise, individual health status can have significant consequences for the health of communities. The health of individuals determines whether they spread communicable disease, influences the physical and mental well-being of their friends and relations, and imposes economic consequences for their families and society. Social connections not only affect disease states but also inform one's self-identity and sense of well-being. Family and community ties provide meaning and worth to life even as they shape the benefits of health and the burden of disease. Concerns over what it means to live a good life may not always be dispositive for questions of public health, but neither are they dispensable. Rather, questions about what public health should do, and how it may be done, are composed of both empirical evaluations about practicability and value-laden determinations regarding desirability.
While public health should engage with bioethics to refine its moral vision, for such an engagement to be fruitful, bioethics must respond to the needs of public health by crafting a compelling theory of value--a moral lens--that can better discern the value-laden questions that emerge when health is viewed from a population level. To do this, bioethics would need to overcome at least two challenges. First, bioethics should articulate a holistic, rather than atomistic, vision of human welfare that includes the value of social and familial relationships that knit individuals together. Second, bioethics must aid public health in identifying achievable moral goals, not just ideal ones. This means grappling with issues of practicability.
While there have been energetic attempts to articulate theories of moral guidance for public health, most such efforts have fallen short because they have viewed populations atomistically, as aggregations of individuals. Utilitarian frameworks have evaluated happiness as a metric common across individuals. Various nonconsequentialist frameworks have sought to identify key morally salient features of humanity that are present in all individuals and deserving of respect. What such theories fail to capture is that relationships between individuals and within communities imbue well-being and determine aspects of health at the population level. Yet much of what constitutes human flourishing consists of the relational dimensions of life: love, friendship, parenting, and communities imbue human life with value. Such factors are not only important determinants of health, but are also the basis for most individuals' sense of physical and spiritual well-being. They are indispensable to any holistic understanding of human welfare and essential to any compelling definition of human flourishing. In developing a moral lens for public health, then, bioethics will also refine or develop the tools needed for other challenges, such as global poverty and environmental concerns. To offer such a moral lens, bioethics inevitably must expand beyond its current conceptual frameworks and grow as a field.
Like many population-oriented fields, public health needs norms that can guide policy toward an attainable good. It must cope with the constrained and contingent nature of social policy and the problems stemming from the practicability of public health interventions. Bioethics would have to become attuned to the population and policy orientation of public health, accommodating the way public health goals are contingent on political dynamics and the limitations of material resources. To that end, bioethics must identify intermediate goals for population health--ambitions that may be less than ideal, but are practicable, attainable, and manifestly better than the status quo.
So-called nonideal theory may, therefore, offer new guiding principles for examining public health. Instead of applying norms derived from moral ideals, such as notions of equality of opportunity or material equality, nonideal theory looks for less-than-perfect but practicable guides. The constrained features of public health practice and the intractability of some of the moral challenges it poses make it amenable to this theoretical approach, which has proved successful in exploring issues like global poverty and racial inequality--topics that are similarly constrained. This framework has room for conflicts between individual and common goods, like individual freedom of movement versus quarantines, that pit libertarian concerns about how we live our lives against concerns about how our behaviors affect others. Often, however, it turns out that these concerns are not in conflict. Rather, improving population health requires improving individual health. Nonideal theory draws on the dynamic relationship between apparently conflicting issues. It is likely to be of great utility in the development of a moral lens for population health.
Bioethics is adept at bringing into focus the moral salience of very small-scale relationships. It has elucidated with astounding clarity the nature of the relationships between doctor and patient or subject and researcher, for example. It has struggled to bring the same moral vision to the macro-scale. It has yet to provide a satisfactory account of how to think about the ethics of health on a population level. Greater engagement with the issues of public health, which might require adopting the methods of nonideal theory, would help bioethics realize this ambition.
Daniel B. Rubin is a doctoral student at The University of Michigan School of Public Health, Department of Health Management and Policy, a law student at The University of Michigan Law School, and a fellow of The University of Michigan, Center for Ethics in Public Life. This essay was written during a summer research internship at the National Institutes of Health Department of Bioethics. The author is grateful to the faculty of the Department of Bioethics for their mentorship and support.
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