1. Should Promotion of Autonomy be a Goal of Public Health? 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 (health care) F Populations (public health) 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, Genetic counselling 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 achieve 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 Reasons in Favour u INSTRUMENTALISM: If people are given the opportunity to choose good health, they will do so to an extent that promotes health. u EXPANSIONISM 1: We have reason to respect autonomy, but there is no sharp moral line between respecting and promoting autonomy. (Consequentialists bent on autonomy – Glover?, Harris?, myself?) u EXPANSIONISM 2: The ideal of respecting autonomy needs the idea of autonomy as a value worth promoting for its justification. (Post- libertarian rights ethicists – G. Dworkin, Feinberg, Zutlevics ) u EXPANSIONISM 3: The more of life and well-being is secured, the more important becomes the promotion of people’s autonomy. (Rawls’ “priority of liberty argument” ‘inspirees’). n Problems u Measuring degrees of autonomy F Defining an interpersonal scale F Modifying public health monitoring instruments u Trade-offs u Can the ideal of respecting autonomy be upheld? Choice of reason will probably make a difference. A battery of ’hard cases’ needed for further thought.

5. More room for side-stepping the duty to respect autonomy? n If the ideal of respect for autonomy is based on the ideal of autonomy as a positive value to promote, presumably, this reason to respect autonomy can be balanced against our reasons to promote other values to a much greater extent than if respect for autonomy is seen as a basic/self-evident “duty of omission”. n Autonomy restrictions presumably even easier to justify on the basis of reasons of autonomy rather than other values – something that is not possible in traditional theories of respect for autonomy as a basic “duty of omission”. F 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 in fact 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.

6. Should a goal of promoting autonomy be adopted in all societal settings? n Instrumentalism: the connection between autonomy and health may vary considerably and in very complicated ways. u “Poor” countries F Lower material welfare ==> more important to choose health F Lower educational level ==> more difficult to choose health F Raising the educational level requires resources that could instead have been spent on directly health promoting efforts. F Raises of educational levels as a rule accompanied by increased material welfare ==> less important to choose health. u “Rich” countries F High material welfare ==> less important to choose health F High educational levels ==> more easy to choose health F Less reason to spend public resources on directly health promoting efforts? (due to weakened willingness to pay) F Less reason to spend public resources on promoting health related autonomy? (due to the weakened importance of health and existing ability to choose).

7. n “Rawlsian” expansionism: no promotion of health related autonomy until a sufficiently high general level of health has been secured, but when that is the case autonomy promotion should be the priority. u The threshold problem F What is the level? F On what basis should it be determined? u Reason for a comparably high threshold (?) F When autonomy becomes the priority it outweighs all considerations of welfare n “Rights-based” expansionism: repeat the above + u Additional reasons regarding the threshold F Should be based not only on the importance of promoting autonomy vs. welfare, but also between the importance of promoting and respecting autonomy ==> further problems regarding the basis. F Since the goal of promoting autonomy may provide reasons for side-stepping the right to have one’s autonomy respected, the threshold should be set very high. n Consequentialist expansionism: whether or not health related autonomy should be promoted depends on what conflicts with other values (life and well-being) will emerge. u Instrumentalism repeated u The trade-off problem