Ethics and equity: Choice or compulsion?

Sim, F.; Mackie, P.

doi:10.1016/j.puhe.2012.01.001

Next »Public Health
Volume 126, Issue 2 , Pages 85-86, February 2012

Ethics and equity: Choice or compulsion?

The Royal Society for Public Health, John Snow House, 59 Mansell Street, London E1 8AN, UK

Article Outline

References
Copyright

Public health and ethics are so closely intertwined that many would contend that the public health department is rationally considered to be the conscience of the organisation. A function that has, at its heart, always to consider what is in the best interests of the population as a whole – not necessarily the interests of individual patients or members of the public, not care providers or carers, nor healthcare systems, but the population in its entirety – is bound by powerful ethical principles, with a strong utilitarian leaning. So it is no surprise that this month, we have some papers that reflect this fascinating relationship between ethics and public health.

We are mindful that by including reference to content material from papers published in this month’s issue in our editorial, we run the risk that either (a) some readers will assume it is done purely for reasons of increasing citations and won’t read further ‘on principle’; or (b) another subset of readers will not bother to read the source article in question having picked up what they think is the gist of it in the editorial. However, neither of these is particularly constructive nor justified and we would encourage you to read the full articles in any event.

Firstly, let us consider immunisation and here one question is, and has been for many years, whether it is justifiable to make immunisation mandatory and if so, in what circumstances is it justifiable? The paper in this issue that addresses this question concerns pertussis vaccine in developed countries.¹ This question has been asked many times and depending upon your school of philosophy, you may respond in favour of individual freedom of choice or in favour of mandating for herd immunity. National political ideology is not always an obvious indicator of these decisions at policy level. The ‘Land of the Free’ has had effectively mandatory selective pre-school immunisation for decades, whilst some far less liberal political regimes favour individual choice in such matter. At the level of the public health evidence-base the answer is more straightforward: higher levels of immunisation amongst the population are a good thing. Yet whether or not it should be mandatory, particularly if an effective level of population protection is not reached by voluntary immunisation, requires separate consideration as risk of harm, however small, needs to be taken into account. So too do other factors such as the impact of removing choice in personal decision making when the benefit accrues largely to others.

The second paper this month that straddles public health and ethics tackles the equally challenging subject of childhood obesity.² At what point in a child’s life is it reasonable to identify the risk of obesity with a view to providing an effective intervention to reduce the prevalence of child and adult obesity? Until relatively recently it has been easy for the libertarians to argue that we do not have enough evidence to impose a solution and that has tended to suppress the case in favour of intervention. But the evidence has grown recently to enable considerably greater confidence in effective early intervention, so that not intervening now has to be questioned. But the wider issues of individual and parental responsibility do not evaporate.

Both of these examples – whether considering immunisation or obesity - concern adult decision making on behalf of their children. Scaled up to the national level, they are about societal decisions made on behalf of the next generation. When it comes to adult decision making, to what extent are we able to interfere with the individual’s autonomy in the context of social justice? Some examples arising recently in the UK concern benefits to which certain selected groups are currently entitled; for example, a winter fuel supplement for older people or free bus passes for everyone over the State pension age. The recurrent debate has been about whether or not such benefits should only be given to those who cannot afford the cost for their own funds: the so called “means test”. Successive governments have left them as universal benefits, so that affluent folk living in mansions and driving expensive cars have as much right to claim them as the poorest in society. Of course, such benefits can be declined, but this seems a relatively uncommon choice. This winter in the UK a group of unlikely activists from among the celebrity classes, campaigned using social media to encourage the better-off to donate their winter fuel payment to charities serving those less fortunate,³ thus bringing about a shift of payment resulting from a combination of self-means testing, ethical decision making and altruism, with redistribution reliant on charitable giving. Whether this societal response as an alternative to public policy is viable beyond selective individual initiatives is doubtful, but it does demonstrate to government the beliefs and values on one topic of those able to exercise choice. Whether or not the money given up by the more affluent ever reaches the pockets of those most in need will probably never be known. Arguably, government is glad that some people do have and exercise their principles for benefit of others, although of course the altruism may be somewhat influenced by the tax benefits to the more affluent taxpaying members of society of charitable giving.

And whilst all this is happening? The social and health inequalities gap is likely to grow ever larger as societies across the globe become an ever more disparate and unequal.

In this Issue

This month readers are challenged about a number of complex ethical decisions that relate to the health of the population, from whether or not immunisation should be mandatory and the merits or otherwise of identifying small children at risk of obesity, to the health impact, if any, of making efforts to reach hard-to-reach people to offer them a health check. We have another paper on the ‘Glasgow effect’ – gradually uncovering the complexity and unexpected contrast with other apparently similar cities in regard to the health of its population. Two papers focus on medical students, who, of course, form an easy, if rather atypical, captive target population in medical schools for all manner of epidemiological and social research: in this issue the students’ tobacco use is examined and in another paper, their readiness to tackle HIV/AIDS.

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References

Girard DZ. Recommended or mandatory pertussis vaccination policy in developed countries: does the choice matter?. Public Health. 2011;126(2):117–122