1. The Goals of Public Health and the Value of Autonomy Christian Munthe Department of Philosophy, Göteborg University

2. Health Policy: Traditional Goals and Restrictions n Goals u “Good health” F Classic determinants: life and well-being F What is to count as healthy enough? F Individuals F Populations F Tensions between the health of individuals and populations u Equality F Tension between good and equal health n Restrictions u Safety F Classic determinants: life and well-being F What is to count as too dangerous? F Trade-off of risks againsts chances of achieving goals u Autonomy F Competent adults are never to be coerced F Measures should never go against the personal wants of patients F Who is competent? F Exception: serious threat to third parties: communicable disease

3. The Emergence of Autonomy as a Goal of Health Policies n Health Care u Reproductive medicine u Genetic counselling (prenetal diagnosis, presymptomatic testing). u Resources may be used and patients may be exposed to risks for the sole purpose of helping them to achieve their personal plans. u A health care measure may be successful even if life and well- being is not promoted u A health care measure may be unsuccessful even if life and well- being is promoted n Public Health (in several rich countries): u The goal is to create societal conditions that secure the (equal) ability of people to achive good health. u That is: the goal is to secure that people can freely choose for themselves according to their personal plans whether or not to promote their health. u That is: autonomy is a positive value to be promoted by health policies, not only a restrictive line that may not be crossed.

4. Reasons and Problems n Possible Reasons in Favour u People will choose good health if given the opportunity (autonomy an instrument for promoting life and well-being). u No sharp moral line between respecting and promoting autonomy (consequentialist reasoning for expanding the idea of respecting autonomy into a positive value to be promoted besides other values). u The more of life and well-being is secured, the more important becomes the promotion of people’s autonomy (Rawls’ argument from the priority of liberty: life and well-being an instrument for promoting autonomy). n Problems u Measuring degree of autonomy F Theoretical problem: defining an interpersonal scale F Practical problem: modifying public health monitoring instruments u Trade-offs F Life/well-being – autonomy, Intrapersonal – interpersonal F If autonomy promotions can be traded off against other values, can the restriction to respect autonomy still be rigidly upheld? F Choice of reason partly determines what trade-offs are acceptable. F A battery of ’hard cases’ needed for further thought.

5. Some Interesting Implications n Having the promotion of autonomy as the goal of public health opens up for more of side-stepping of the duty to respect autonomy. u Autonomy restrictions presumably easier to justify on the basis of reasons of autonomy rather than other values. u Smoking in public places: staff is not given the opportunity to choose a smoke-free life if smoking is allowed. This holds even if no one would like to have a smoke-free life and even if tobacco smoke is not harmful enough to third parties to motivate autonomy restrictions according to the classic model. n Whether or not the goal of promoting autonomy should be adopted in all countries depends on what basis it is justified. u Instrumentalist: the connection between autonomy and health may vary considerably between countries, regions, cultures etc. u Rawlsian: a country should adopt promotion of autonomy as a goal of public health only if the general level of health is sufficiently high. u Pluralist consequentialist: depends on what conflicts with other values (life and well-being) will emerge: the trade-off problem.