“The field and concept of public health, by definition, involves the making of policies which seek to improve the health of populations. Inevitably, this involves the appraisal of epidemiological data and consideration of which measures will improve health and prevent disease if applied on a large scale. On such a scale, it is generally not possible to consider all possible personal and individual contexts, perceptions and preferences. Yet the vast majority of health care providers – including midwives – work directly with individuals. Furthermore, our professional obligations and codes of conduct clearly state that we have a duty to ensure that those individuals can make informed choices about their health care and experiences. Just as there is a tension between the notion of informed choice for individuals and the recommendation of target uptake figures for particular screening tests offered within populations, are there also wider tensions between the concept of public health and our desire to be with woman?”
Liberty or Patriarchy?
There exist widely divergent views on whether governments should take more of a liberal or patriarchal view in relation to public health. Economist Robin Hanson favours an individually-focused, libertarian approach. He raises a number of radical but nonetheless fascinating questions about paternalism in health care and public health:
“Why do we feel we should regulate health and medical choices so differently from other choices? Why do we think people with all the usual human frailties are better off with the freedom to choose their own sex life, roommates, careers, places to live and children, but not their own food, drugs, cars, and medical advisors? Sure some health choices are hard to reverse and have big consequences, but so are many far less regulated choices such as changing nations or having babies. And we remain paternalistic about even small reversible health choices.” (2008: 910)
The term ‘nanny state’ is increasingly used by those who are critical of the more paternalistic approach which they perceive has traditionally been taken towards public health. This term was used in the UK press in response to the Nuffield Council on Bioethics (2007) report, which sought to create an ethical framework that would help clarify the difficult and often overlapping issues that arise when we consider the rights of the individual to make choices alongside the responsibility of the state to ensure it is doing all it can to improve health and prevent illness. By contrast, a Lancet (2007) editorial commended the report and condemned the press reaction as unfair in the light of the global rise in problems related to obesity and illnesses which are linked to the use of substances such as alcohol and tobacco.
In seeking an appropriate balance between the agency of the individual and the needs of the population, the Council recommended a modification of the libertarian approach into a stewardship model as an alternative to paternalism while also noting that, “concern for the needs of the population as a whole means that very demanding interpretations of individual consent as an expression of individuality and autonomy should be viewed with caution” (25). It is perhaps inevitable that such statements might concern those of us who seek to help individuals to make choices and become empowered; women’s agency is considered to be a cornerstone of good midwifery care and threats to women’s autonomy may thus be seen as intolerable. Within the woman-centred ideology that many midwives espouse, the notion of the uptake targets mentioned above may be deemed inappropriate on the basis that the midwife’s target is to help every woman to make her own decision with her family and within the context of her own life and situation.
Yet the very act of seeking to make guidelines which are applied to entire populations involves the need to make decisions about what is best on aggregate, or overall, or for the greatest number. There exists huge variation in the degree to which different individuals are willing and / or able to take responsibility for their own health as well as in the varying expectations that we each hold about the extent to which Governments should take steps to control the health behaviours of others, especially when those behaviours may affect us on some level. The recent move in many countries to ban smoking in public places (and the subsequent responses to this ban, both formal and informal) is merely one example of the way in which it may simply be impossible to please all of the people all of the time.
The Nuffield Council on Bioethics (2007) report itself acknowledges that some public health measures are intrusive and it includes a rather useful depiction of an intervention ladder which recognises that public health policies can affect people’s choices in different ways. The levels of action that the state may consider are described by the different levels of this ladder and they range from doing nothing (except perhaps simply monitoring a given situation or issue) right up to the extreme measure of introducing laws that eliminate personal choice, for example where people with certain infectious diseases are forced to be quarantined or isolated from the population at large for the protection of others.
Protecting the Other
The notion that is it more acceptable to force behaviours, restrictions or interventions upon people when their personal health status or individual decisions have the potential to affect others than when their choices will only affect themselves might not seem unreasonable in the context of making decisions about public health. Indeed, the report under discussion clearly differentiated the unacceptability of coercing individuals into making healthy choices from the importance (and acceptability) of reducing the risks of disease that some people might impose on others. Another key issue concerns protection of the health of vulnerable groups, including children. The issue that all pregnant and birthing women face, of course, is that the very nature of pregnancy ensures that their health and health-related decisions always carry the potential to affect at least one other person, and a vulnerable one at that.
As any of the volunteers who staff help lines for women seeking advice about their rights and their options will attest, it is not at all uncommon for women to be strongly advised to take a particular course of action on the basis that it is best for their baby. On occasion, the threat of legal action is used to force the issue. Given the range of perspectives that exists, we may never all agree on whether this is always and absolutely unjustifiable or whether there are occasions on which such action may be ethically justified. The complexity of this issue is compounded by the fact that both professionals and the recipients of care may draw different conclusions from the same evidence because our interpretations of this evidence are filtered through existing ideology and experiences.
The issues raised by even a brief consideration of the ethical principles in this area are enormous, and they have the potential to affect all of us. Midwives and researchers have been exploring the complex areas of power, autonomy and choice for a number of years and many questions, tensions and conflicts remain. The conflict that exists between the needs and rights of the individual and the needs and rights of the population is complex, contested and controversial. Given that this debate is ongoing at various levels of Government and within other groups who have an interest in this area, however, I believe it is one with which women and midwives simply have to engage.
Nuffield Council on Bioethics (2007). Public Health: ethical issues. London: Nuffield Council on Biethics.
The Lancet (Editorial) (2007). The Lancet 370(9602): 1801
Robin Hanson (2008). Making sense of medical paternalism. Medical Hypotheses 70(5): 910-913
This was originally published as Wickham S (2009). Choice, liberty and public health. TPM 12:5, 4-5.