Introduction
Autonomy in public health is defined by the concept of people making their own rules and choices (independent of others) (E notes 2011, p. 1). This means that autonomous persons are able to make their own choices and live by the design of their plan. In contrast, a person who lacks autonomy is an individual whose actions and behaviors are controlled by others (somewhat). For instance, mental patients who are confined in institutions (or prisoners who are incarcerated by the government) lack autonomy. The fundamentals of autonomy state that, patients can choose to ignore their health, regardless of if it benefits them or not (Beauchamp and Childress 1989, p. 1). The American Medical Association defines autonomy as “A patient having the right to make decisions regarding the healthcare that is recommended by the physician. Accordingly, patients may accept or refuse any recommended medical treatment” (E notes 2011, p. 1). For instance, patients have been known to ignore conventional forms of treatment in place of alternative forms of treatment, or natural forms of treatment, even though it may negatively affect their health. In this context, patients have even been known to die from making wrong health choices (E notes 2011, p. 1).
However, despite the negative consequences of patient autonomy, medical practitioners are required to respect patient autonomy always. Nonetheless, in times of quarantine (or other unique health circumstances), public health practitioners may infringe on a patient’s right to autonomy (E notes 2011, p. 1). For instance, in situations where parents refuse to vaccinate their children, the parents’ right to autonomy may be contravened to protect the rights of the children. Nonetheless, in the context of public health, autonomy is viewed as the ability of a person to make informed consent regarding public health initiatives. The focus on autonomy has especially been recently brought to fore with increased emphasis of the importance of ethics in undertaking public health activities (Callahan, Jennings 2002, p. 192).
This paper seeks to analyze the importance of autonomy in public health, with a special emphasis on its application in public health ethics. Firstly, the paper explains the importance of autonomy in undertaking public health research as a special branch of public health studies (with a special emphasis on community autonomy). This will be explained in the context of researchers seeking permission to undertake studies in a community setting. Secondly, this paper focuses on the general application of autonomy in public health, with regards to legal considerations in public health research. This will be followed by an analysis of the application of autonomy in public health economics. Fourthly, this paper seeks to explain the application of public health on relational ethics. In this context, the consequential perspective of autonomy (and autonomy as a means to an end) will be analyzed. This paper also explains public health as the means to upholding ethical practices, with a special reference to how it supplements disaster and emergency responses, and how it upholds environmental justice. Lastly, this paper explains how public health supplements healthcare reform as a means to improving the quality of public health services. In this analysis, an explanation of how autonomy fosters accountability and improves the provision of quality public health services to the community will be explained.
Autonomy in Public Health Research
Since public health is mainly community-oriented, by design, it is supposed to improve the overall health of the community. However, this cannot be done without first observing individual autonomy. Often times, individual autonomy has not been observed by most public health experts (Tyrer 2008, p. 4). This has attracted both comments and criticisms from the public. Currently, there is a global emphasis on the importance of observing ethical practices whenever public health research is done (Hall 1992, p. 197). This is observed in the context of public health researchers obtaining informed consent from their subjects before any research study is done. Currently, most research studies are reviewed by ethical committees which establish if research is done in an ethical manner (that observes subject autonomy and the appropriate balance of risks and benefits associated with undertaking any public health research) or not (Pattison and Stacey 2004, p. 622).
In developed countries, there is a certain degree of strict observance of ethics while undertaking public health studies. However, there is a considerable degree of subject violation of individual autonomy when undertaking public health studies in the developing world (Council of International Organizations for Medical Science 2000, p. 3). In these countries, several episodes of intimidation or coercion have been evidenced. In such cases, it becomes increasingly difficult for ethical committees to review subject autonomy whenever any public health research is concluded. In contrast, in the developed world there are established mechanisms which allow ethical review committees to evaluate subject autonomy in public health studies.
In the developing world it may be extremely difficult to obtain informed consent from research subjects if there is a high illiteracy level (Whitney, McGuire and McCullogh 2003, p. 54). Sometimes, it may be equally difficult to obtain informed consent from subjects if the consent has to be obtained from the community leadership (besides individual consent). Such situations become tricky for public health researchers because besides respecting the community’s culture, they also have to respect individual autonomy. However, it should be understood that, since public health is focused on community health, there is a strong inclination for public health experts to ignore individual autonomy. In the development of any public health intervention, two factors should be considered. First, the rights of individual community members (in the context of the community culture) should be understood. Secondly, the autonomy of the community as a whole should also be understood. Each of these facets of public health has a significant bearing on public health. However, it is more important to understand the importance of community autonomy in public health.
Community Autonomy
Communities exist within the framework of some form of social construct whereby if such contracts do not exist; the existence of a community cannot be sustained. Since communities exist with the sole aim of ensuring public safety of all their members, the concept of personal freedom is very important (Hall 1992, p. 197). This concept is defined by individual autonomy. In certain community contexts, the concept of personal autonomy is integrated with economic and social benefits, such that, individual ties within a community bear the framework of the community’s existence. In these types of community setups, the main aim of a community’s existence is to provide socio-economic benefits to its members (such as food and housing). Also, in the same context, community members are likely to pressure individuals to act for the benefit of the community as a whole. This form of community organization is not the same as a minimalist community which finds it difficult to preserve individual autonomy because they exist in the middle of a moral chaos (Powers and Faden 2006). Nonetheless, minimalistic communities are rare to find.
In the conventional community setup it is therefore increasingly difficult to violate individual autonomy because individual autonomy is closely related with the community’s wellbeing. In this type of environment, any form of community intervention must be done with a close observance of its implication on personal autonomy. In this type of environment, individuals hold the right to decline any form of participation in public health initiatives. However, there are some cases where paternalism may be evident, in the sense that, a community intervenes to protect individuals against making ‘unwise’ decisions when it comes to public health decisions. A mutual relationship is hereby realized because communities are perceived to benefit by helping their members make the right choices. Here, paternalistic interventions seem to contravene individual autonomy. However, these interventions are often justified from the fact that, they are aimed at upholding the “welfare, good, happiness, needs, interests or values of the person being coerced” (Hall 1992, p. 201). This form of personal autonomy interference is a very ‘hot’ topic in modern science because reference has been made to a spartan-like regimes where physical exercises are encouraged, without unwise lifestyle behaviors like excessive drinking and smoking (Hall 1992, p. 207).
A renowned philosopher, JS Mill, has been on record to speak against paternalism because he advocates for a highly strict form of philosophy that does not condone lies and similar negative behaviors. However, there is a more subtle approach to the entire debate which approves of paternalistic influences, so long as certain conditions are observed. Part of the reason advanced for this gentle approach to paternalism is the fact that, whenever people associate with a certain community, they cede their personal autonomy somewhat. Personal autonomy is therefore regarded as a price to pay for community membership. Nonetheless, these insights strongly appeal to the concept of autonomy, based on the fact that, they are designed to ensure that personal freedoms or wishes are respected.
In the same manner a parent cares for a child or a state cares for its own citizens (especially those who are incompetent), the concept of paternalism finds its footing. However, regardless of the situation, the moral justification of the action must be proved. Nonetheless, despite whatever perspective is taken of the community or the concept of paternalism, autonomy is crucial in both analyses and it must be observed always.
Legal Considerations
Considering the concept of autonomy is perceived from an ethical point of view, it is difficult to distinguish it from the law because ethics and law are closely integrated with one another (Childress, Faden and Gaare 2002, p. 170). From this understanding, the concept of autonomy in public health can be perceived from a legal point of view. This legal point of view defines the limits public health can go with regards to implementing public health interventions. In the past, public health has been closely associated with law. For instance the US Public health disease control act of 1984 and the 1904 US Supreme court ruling on vaccination are good examples of how public health initiatives are constrained by law and how autonomy is interfered by the law (Centers for Disease Control and Prevention 2003, p. 1).
For instance the 1904 US Supreme court ruling which stipulated that, people could be fined for not taking vaccination set the precedent for subsequent legislations on public health (from a legal point of view) (Hall 1992, p. 201). Though the Supreme Court ruling is an old one, it is a special case of the US public health system because it defined the extent public health initiatives could be implemented. Often, this case is referenced whenever there is a reason to justify government interference on personal autonomy in public health cases. There is however, a serious debate going on to determine the point where governments should interfere with personal autonomy. However, it is assumed that, if there is a serious health threat in a community, the government may intervene by intruding on personal autonomy.
Nonetheless, the influence of the government in the determination of personal autonomy has taken a new perspective, with recent debates gravitating towards more ascertainment of individual autonomy. As a result, there have been more experts coming out to dispute the influence of the government in determining public health interventions. For instance, Hall (1992) says,
“There is, of course, a sphere within which the individual may assert the supremacy of his own will, and rightfully dispute the authority of any human government, – especially of any true government existing under a written constitution, – to interfere with the exercise of that will’ (26).
The recent emphasis on individual autonomy has been extended to repeated incidences of suicide and life support withdrawal. For instance, it has been suggested that suicide should no longer be perceived criminal because it falls within the right to personal autonomy, and more importantly, the right to determine someone’s destiny (Hall 1992, p. 201). The same suggestions have been made to change the perspective of the healthcare fraternity in allowing terminally ill patients to switch off their life machines (Laine and Davidoff 2011, p. 152). The situation is not any different from the modalities used in public health to test patients through screening of various diseases (Burke, Coughlin and Lee 2001, p. 201).
Recent pandemics such as the AIDS scourge have changed the way legal perspectives about public health and personal autonomy should be perceived. For instance, in the US, many legislative changes have been made to grant a high level of confidentiality to people suffering from AIDS. This is a departure from the past because past legislations advocate for the identification of disease carriers if any public health pandemic occurs (Hall 1992, p. 201). In this context, individual autonomy is deemed more powerful to the interest of public health.
Economic Considerations
In recent times, there has been increased focus on the sustainability of public health interventions in the wake of scarce resources. Many governments are therefore reassessing their economic priorities, with regards to how much money can be spent on healthcare and how much should be spent on other socio-economic initiatives. Regardless of the dilemma, doubtless, many governments are increasingly faced with a tight economic situation where they have to seek more economically sustainable means of sustaining public health initiatives. This pressure is felt despite the fact that, the cost of healthcare is increasing globally. For instance, in the US, the cost of treating hypertension has doubled over the years. Moreover, there is no payoff that has been realized from the reduced cases of stroke or heart attack.
In the US, the government is slowly reassessing its priorities with regards to how much money can be realistically spent on healthcare, considering the cost of healthcare is quickly increasing and almost equally, there is an increased need for more healthcare services. Burke, Coughlin and Lee (2001) explain that:
“It is now almost universally believed that the resources available to meet the demands for healthcare are limited…. We as a nation [US], will have to think very carefully about how to allocate the resources we are willing to make available for health care” (p. 221).
The bulging population of baby boomers is one such example which is exerting more pressure on the country’s healthcare system. The questions of distribution and access to public health therefore prominently feature in this analysis because there are minimal resources to be spent on public health as a whole. These economic pressures are known to affect significantly public health decisions, but as will be evident in further sections of this study, this concern is directly related to the concept of autonomy in public health.
Since there is a rising cost of healthcare services worldwide, there is growing concern regarding the economic costs of treating common diseases. In fact, some of these treatment costs have elicited ethical concerns regarding the sustainability of these healthcare costs for common citizens. In the same debate, there have been more ethical concerns raised regarding the assumption that, it is not appropriate to screen colon cancer, despite its commonality (Hall 1992, p. 201). These issues are becoming very common in public health because besides conventional factors affecting public health initiatives, there is the economic consideration to be observed before implementing any public health initiative. For example, some observers note that, it is unethical to undertake public health initiatives which are deemed low-yield.
Nonetheless, the connection of this analysis with public autonomy is evident in the fact that, with increased healthcare costs, it is expected that in the coming years, there is going to be more focus on the assertion of preventive strategies as opposed to treatment strategies because it is cheaper to undertake preventive public health initiatives as opposed to corrective public health initiatives. The main motivation behind this change of paradigm is the high economic costs of treatment and the relatively low costs of preventive strategies. In the coming years there is going to be more focus on public health initiatives centered on health promotion, disease prevention (and similar initiatives) because they are more cost-effective than healthcare treatment services. However, for such initiatives to succeed in present-day society (of increased awareness of personal autonomy), the autonomy ought to be effectively considered when designing public health initiatives. For instance, health promotion strategies are going to fail if they are not designed with patient or community autonomy in mind.
Relational Ethics
Relational ethics is a concept in public health which is aimed at fostering good relationships between people and public health officers (Lambert 2003). The main subject in this theory is an abstract individual whose qualities are not easily known. However, the main principle behind the relational theory is the regulation of human relationships. This relationship is characterized by a gap between what is expected by the public health officers and what is desired by the individual entities. For instance, the main role of public health in the society is to sensitize people against the health risks that surround them, and how they can make the right decision to protect themselves in this regard. However, contrary to the wishes of public health officials, individuals decide to make decisions which do not conform to the wishes of public health officials.
On one side, public health has failed to empower individuals to make the right decisions about their health, and more so, understand the health risks that surround their daily activities. For instance, there is a growing field of study emphasizing the importance of public health officials to equip people with the “right to know” (Hall 1992, p. 201). This suggestion has been motivated by the increasing number of public health accidents such as the release of isocyanate in Bhopal, India which killed thousands of people and injured many more (Dhara, Dhara and Acquilla 2002, p. 487). There is therefore a growing body of knowledge which advocates that, people should be empowered with the “right to know” the health risks that exist around them (Hook and Lucier 2000, p. 160). From a narrow point of view, communicating to the public the health risks that surround their daily operations occur within a narrow scope of public health communications which is defined by relational ethics (Public Health Leadership Society 2000).
This communication can only be implemented through a mutual relationship between public health officials and individual persons. This occurs as one-way form of communication or a two-way form of communication. The one-way form of communication is implemented through the flow of information from public health officials (and organizations) to the community. The two-way form of communication occurs if there is a constant back-and-forth flow of information from public health officers to individual persons (Wynia, Coughlin and Alpert 2001, p. 100). The former has been used for the past two decades but recent times have seen a change in paradigm. Nowadays, there is more focus on the importance of respecting individual wishes even in the wake of constant awareness of public health risks. Nonetheless, the “reasonable person standard” is a central concept in the flow of information between the two zones of information flow because public health officers expect any reasonable person to decipher useful information and use it for personal protection and safety. However, the relationship between public health officers and individual persons should not only be evident in cases where there is a catastrophe. There should be a constant flow of information from both points of contact in all environmental and public health initiatives.
It is from this point of view that the importance of autonomy prominently features in the implementation of public health initiatives. The concept of autonomy is useful in this analysis because the frameworks used to solve our problems of moral choices are dependent on the perspective we choose to analyze the problem, or the framework used to solve the same. Autonomy forms the foundation of relational ethics because it is at the core of relational ethics which fosters the right to know (American College of Epidemiology 2000, p. 487). However, relational ethics operate within the confines of several perspectives (Singer, Benatar and Bernstein 2003). One such perspective is the consequential perspective.
Consequential Perspective
The consequential perspective identifies that the right to make any right or wrong decision entirely depends on the consequences to be realized as a result of the decision made. From a non-judgmental point of view, the consequential perspective is designed in a manner that produces the best overall result in any given moral dilemma. This product also has to be tailored to meet the interests of everyone involved. The consequential perspective is therefore enshrined in the seductive principle that the good of the majority should be realized by minimizing any possible occurrence of evil. The Canadian journal of public health identifies this paradigm as the main principle which public health ethics is enshrined in (Fairchild and Bayer 2004, p. 631). However, this point of view is contested by many critics because it contravenes the good of others for the greater good of the majority. Here, immorality is fostered. This is also the same context in which individual autonomy in public health is realized.
For example, often times, people from marginalized segments of society pay for the societal costs of achieving a greater good of the majority. The US public health has been seen to fall prey to this fact, as was evident in the Tuskegee Syphilis experiment where a group of African American patients suffering from Syphilis were denied treatment so that the disease could be analyzed to understand its patterns (Adams 2002, p. 1). The most unfortunate fact is that, the patients were denied treatment even though there was an existing course of treatment for the disease at the time. The experiment was conducted from 1932 to 1972 (Adams 2002, p. 1). When analyzed from the consequential perspective, this action was justified because it was done for the greater majority of all Americans. However, this option contravened individual autonomy because the action was imposed on the patients.
The same situation was also evident in Canada where the Alberta government decided to sterilize a group of mentally ill patients because they did not want them to procreate and produce another generation of mentally ill people (Adams 2002, p. 1). The main point of analyzing the two examples is that, the patients were not given a choice to determine how the treatment methods would add value to their lives, as opposed to the lives of others. The main payoff for the Tuskegee experimental group was the overall understanding of Syphilis while the Alberta group program was aimed at improving the overall intelligence of the population. From this point of view, we see that, the consequential perspective disregards any element of justice of fairness (Kass 2004, p. 232). However, more importantly, we see that the consequential perspective does not regard any element of personal autonomy. From this perspective, we can establish that, the consequential perspective is a wrong strategy of undertaking public health initiatives. Furthermore, it does not have a place in modern-day society where autonomy is strongly considered above most factors in public health. This is an example of how the neglect of autonomy in public health leads to a moral disaster.
A means to an end
Since we have already established that relational ethics is highly dependent on the concept of individual autonomy, it is correct to note that, individual autonomy is crucial in the context of public health because it seeks to merge the gap between public health initiatives and individual decision-making concepts (Bayer and Fairchild 2004, p. 473). The latter concept is supported by the “person stand alone” model which advocates for individual autonomy at the expense of all other factors in public health. Adams (2002) explains that, this model “embraces the idea of autonomy as noninterference, generally held in nondirective counseling, neutral risk communication, and consumer models of health care” (p. 134). In other words, autonomy is the middle-point where public health, the community and individual persons operate in a mutually-benefitting framework. However, as is explained by Hall (1992), this framework operates within five core pillars:
“a) developing and maintaining an open mind; b) developing one’s own perspective; c) seeking the opportunity for creative insight and new facts to modify one’s prior perspective; d) seeking the opportunity for expression of the perspectives of others; and e) generating motivation to care for each other and the environment” (p. 222).
These pillars ensure that all stakeholders within the autonomy framework can benefit from everyone through free information exchange. Autonomy is therefore a means to an end in upholding the “right to know”, which is at the centre of public health initiatives.
The Means of Ethical Practice
Disaster Planning and Emergency Reponses
Often times, the concept of autonomy is beneficial when trying to implement disaster planning and emergency responses in an ethical manner. In most public health disasters, the health risks are often very detrimental and acute. Such was the situation evident in India’s Bhopal disaster which killed 8,000 people and injured another 50,000. Hall (1992) notes that, the impetuous for public health initiatives (preventive measures which are based on warnings) are based on the certainty of understanding a given risk. When public health officials understand the causation impact of any given public health risk, they can design and implement public health initiatives in an amicable manner. This is often easily achieved because facts speak for themselves. However, there may be a gap in communication whereby, the understanding of when these facts speak for themselves is unclear. For example, it is not easy to establish how the community should understand facts about these public health crises and preventive strategies. Equally, it is not easy to establish if they need to have a say in the design of these public health initiatives (Gostin 2001, p. 321). Often times, public health intervention occurs when a disaster has already been experienced.
As explained in earlier sections of this study, the community should be empowered with the right to know which type of health risks they are exposed to. In turn, this means that, they should be included in the development of public health initiatives that affect them. This should be implemented though these initiatives may have a high probability of failure. Prevention strategies are normally perceived to be the main criterion for undertaking public health initiatives (Hall 1992). However, in undertaking these preventive actions, several stakeholders (apart from the community living closely) need to be involved.
It is however impossible to create a structured framework for designing and implementing these public health initiatives if the impetuous of the “right to know” is not effectively implemented (Seigel 2003, p. 3419). For instance, in a situation where a community lives in a place which predisposes its members to extensive health risks, the “right to know” helps in enabling the community to get out of harm’s way. Hall (1992) however advocates for the use of paternalism in moving “endangered” persons from environments which pose severe health risks. Besides paternalism, Hall (1992) advocates for a strong use of coercion, manipulation and force to move communities from areas that pose severe health risks. In his perspective, this involves the erection of barricades to prevent people from making unwise choices regarding their health. However, the extent which their strategies should be implemented is often questioned by most public health experts. For example, erecting a barricade cannot solve the eminent threat of preventing toxic fumes from reaching a community (if that is the case).
The concept of autonomy prominently surfaces as a viable strategy to solve the above problem because it provides a framework where the public can share in the impetus to reduce the health risks posed by the environment. The concept of autonomy is closely linked with the concept of “the right to know” because people need to comprehend why public health initiatives advocate for certain strategies like evacuation, verbal injunctions, erecting barricades and such drastic measures. Fostering the concept of understanding in such situations go a long way in making people to start caring for their own health, but more importantly, it enables people to start caring for the welfare of others. To a great extent, this intervention increases the scope and outreach of public health initiatives. Here, the concept of autonomy is seen as a crucial tool to implement preventive public health strategies. Though coercion, force and manipulation may work somewhat, it is more effective to empower the community with the “right to know” so that its members can complement public health initiatives voluntarily. In contrast, this strategy works more effectively than imposing fines, issuing threats and such like factors. Moreover, these strategies do not respect individual autonomy.
Environmental Justice
Environmental justice is a crucial aspect of public health because public health seeks to carry out environmental impact assessments to establish the health risks posed by several environmental factors on the community (Lee 2002, p. 141). For instance, the fact that industrialization has brought several ethical concerns regarding the release of toxins to the environment is a strong cause for concern within public health circles. For example, the increased number of industrial activities in the Western world has transported several toxins to the Northern part of the globe through atmospheric transfers and other natural processes. As a result, there is a strong threat of communities inhabiting the Northern part of the world to suffer from health risks associated with toxin pollutions such as mercury and toxaphene (Perlin and Wong 2001, p. 2) Contrary to past pollutants such as DDT and toxaphene, mercury is still produced in large quantities in the Western world, in countries such as Canada and the US (U.S. EPA 2002, p. 1). This toxin production still goes on in unregulated proportions because industries which rely on coal power still produce the pollutant in large quantities.
Taking mercury in isolation, there is no preventive or precautionary measure currently undertaken to ensure the community affected by its production is safe from its effects (Clarkson 2002, p. 11). The situation is only getting worse with governments increasingly seeking newer ways of generating electricity, at the expense of the environment. For example, the Alberta government in Canada is increasing its coal use for the production of electricity (Macdonal and Barrie 2000, p. 5). Though the environmental impact of mercury production from one factory may be negligible when compared to the global impact; collectively, these industries severely impact the livelihood and health of the communities affected by their activities. For example, there have been increased concerns over the contamination of food and breast milk in several regions across the globe as a result of environmental pollution. In fact, the culture of some communities affected by this environmental impact is under threat.
Though many risk assessment initiatives have been encouraged on many levels, there is a consistent neglect of immeasurable factors arising from environmental pollution (Kriebel, Tickner and Epstein 2001, p. 871). This reason has prompted many people to expand their perspective of environmental risk because there needs to be more consideration of extended measures that encompass health risk assessments of factors which cannot be quantified within any given metric. For instance, it is not clear how to quantify the environmental impact of coal use on children, adults or animals, considering coal is still an unexploited form of energy that lies underground in large quantities. When analyzed from the consequential perspective, the eminent health threat lingering for the communities living in the north is a price to pay for the greater good of the majority. However, this perspective poses some serious ethical concerns because continuing with these operations mean that, we neither have any respect for the plight of the poor, nor do we have any respect for the environment which supports our very own existence. The biggest concern however lies in the fact that, there are still no strong strategies for exploiting these natural resources without causing any severe environmental harm. This is a pressing question in public health.
However environmental justice suggests a community-based approach. This approach is strongly enshrined in the concept of autonomy. For instance, the communities of the North (which are affected by mercury emission) should influence policies regulating industrial activities in most world economies such as China, USA, UK, Canada and the likes. This analysis prompts the understanding that a purely community-based approach is not sufficient in addressing all public health concerns associated with environmental justice. The respect of autonomy should therefore be integrated with political will. If personal autonomy is disregarded, there is a high possibility that the society will keep making decisions which reproduce past environmental injustices and more so, decisions which do not address humanity concerns, the way public health strives to. Respecting autonomy is therefore a pivotal concept in achieving desirable public health outcomes.
Public Health Reforms
Autonomy has been conventionally perceived from the individual or personal point of view. However, autonomy in public health can also be perceived from an institutional framework, where public health initiatives are undertaken by health institutions which require autonomy when formulating or implementing public health initiatives (Govindaraj 1996, p. 1). In this segment of the study, focus will be made to developing countries where public health initiatives are majorly carried out by health institutions such as hospitals. However, emphasis will also be given to the crucial role autonomy plays in demanding public healthcare reforms around the globe.
In many countries across the globe, there is consensus that healthcare systems need to be redesigned to address the current healthcare needs of the population. However, the same consensus evident in realizing this need is not felt in charting the way forward to achieve these reforms. In the past, many governments have experimented with various strategies aimed at improving efficiency in the healthcare sector without privatizing health institutions because of the obvious acknowledgement that privatizing health institutions is going to lock out several people from accessing healthcare services. It is from this understanding that autonomy is perceived to play a central role in eliminating the inefficiencies and bureaucracies observed in public health facilities. These calls for autonomy can be felt financially or otherwise (AAMC Task Force on Financial Conflicts of Interest in Clinical Research 2003, p. 237). However, the link of autonomy with public health is strongly felt from the fact that, most countries depend on their health institutions to formulate public health initiatives.
For instance, in most developing countries, governments are looked up to, for the provision of public health services, and they live up to their task by using public health hospitals. Though the impact of the government is strong in the developing world, governments in the developed world also play a significant role in the provision of public health services to the population. The financing for most public health services have also been felt from the public health side, though in recent times, scarce resources have seen public health funding from governments diminish, or fizzle out altogether (AAMC Task Force on Financial Conflicts of Interest in Clinical Research 2003, p. 237). Since there is a lot of pressure to provide healthcare services despite minimal economic resources, most countries across the globe including Zambia, Egypt, Colombia, Mexico (and the likes) have embarked on a strategy to reform their healthcare sectors. These reforms are aimed at improving the provision of public health services.
These reforms are mainly aimed at achieving economic efficiency, whereby the same levels of output can be achieved at minimal costs. The recent publication by the Word Healthcare organization, “Investing in health” has led to the growing currency of pursuing cost-effective ways to undertake public health initiatives (AAMC Task Force on Financial Conflicts of Interest in Clinical Research 2003, p. 237). Most governments are at the forefront in initiating these reforms because it has been proved that most governments (especially in the developing world) greatly finance healthcare initiatives. For instance, AAMC Task Force on Financial Conflicts of Interest in Clinical Research (2003) explains that, more than 60% of all public health budgets sampled in more than 29 developing countries came from the government. Of the 29 developing countries sampled, it was affirmed that only two received less than 40% of government funding. Therefore, two thirds of the countries sampled received more than 50% of government spending for their public health initiatives.
Apart from the widely acknowledged fact that this kind of funding is unsustainable in the long run, there is more consensus on the fact that, governments do not get value for money from these investments. This is based on the fact that, public health institutions are experiencing a lot of inefficiencies. These inefficiencies are observed in the context of technical inefficiencies and allocation inefficiencies. Ironically, despite the huge investments in public health, it is affirmed that, the government greatly contributes to the inefficiencies experienced in the public health sector. The World Bank has recommended that there needs to be a paradigm shift from an independent decision-making organ to a more distributed form of decision-making (AAMC Task Force on Financial Conflicts of Interest in Clinical Research 2003, p. 237).
Autonomy has therefore been advanced as a possible pigment to the realization of these initiatives. Fostering hospital autonomy is also suggested as a possible method of improving public health because it encourages competition, achieves a split between purchasers and providers of healthcare services, restructures public health institutions to resemble the structures of private health facilities (without necessarily being private), encourages decentralization, improves community involvement, initiatives managerial and budgetary reforms, and reallocates public sector budgets to be more sensitive to the needs of the community in an efficient manner (AAMC Task Force on Financial Conflicts of Interest in Clinical Research 2003, p. 237).
Accountability
Upholding hospital autonomy is bound to increase the level of accountability when undertaking public health initiatives. The basis for this assertion is that, healthcare institutions which have a stronger sense of autonomy are likely to better respond to the local needs of its community. This observation is expected to be a mutual relationship where the community is likely to respond positively by supporting the initiatives of the healthcare institutions by ultimately taking part in the decision-making system of the health institutions. In this context, if authority is delegated to healthcare institutions, such that, they make their own decisions, there is bound to be a development of systems and control that will ensure the increased authority is used for the benefit of the stakeholders involved. However, this should be done with consideration of the fact that, it is possible for healthcare institutions to use their autonomy to advance selfish interests, or the interests of politicians or sponsors. This can only be realized if equity is compromised (Anand, Peter and Sen 2000). This concern should however be checked to ensure it does not happen.
Better Quality of Public Health Services
It is affirmed that, the grant of autonomy to public health centers is likely to increase the quality of the healthcare interventions undertaken by public health institutions. For instance, Anand, Peter and Sen (2000) affirm that, if health institutions are granted autonomy (among other incentives such as consumer responsiveness, public accountability and the likes) they are likely to respond by improving the quality of their public health initiatives. This improvement in service quality can be witnessed from the employment of more qualified personnel, procurements of better equipments, optimal deployment of personnel and such like initiatives. Also, part of the reasons identified to lead to better public health service delivery emanates from the fact that, granting hospital autonomy is likely to separate politics from the provision of healthcare service delivery. Since most public health agencies are tied to a higher authority (which is normally the government), they are unable to isolate themselves from the politics that go on within government. In the same manner, they find it increasingly difficult to avoid the bureaucracy that is normally evident in government. An elimination of this element is therefore likely to lead to better provision of public health services.
In a study done in Kenya, Kenyatta National Hospital (which is the biggest public health facility in the country, and indeed the wider East African region), was observed to suffer from poor public health service delivery because of the strong control the government, through the ministry of health (Anand, Peter and Sen 2000). The hospital therefore failed to deliver in its public health role because it suffered frequent episodes of managerial inefficiencies, brought about by a lack of autonomy. These inefficiencies were also seen to spill over to areas of public health service delivery and in-patient healthcare service delivery. For instance, the hospital was observed to suffer from overcrowding, provision of low quality care, insufficient stocks of healthcare equipment, and a lack of commitment among the healthcare personnel in providing quality care to patients (Anand, Peter and Sen 2000). Though a lack of autonomy was identified to be the central cause for these inefficiencies, poor management, inadequate staffing, a centralized decision-making system and a lack of effective control systems were identified as auxiliary factors leading to the poor state of the healthcare facility. From these healthcare challenges, the government ceded some of its control on the healthcare facility and from increased autonomy; public health service delivery has significantly improved. Moreover, the quality of delivery of public health services has doubled over the decade (Anand, Peter and Sen 2000).
The same situation was also replicated in India (APVVP hospitals) because the government was experiencing extensive challenges in funding public health initiatives (which compromised the quality of public health services). The government later decided to grant all district level hospitals the autonomy they needed to improve their services and establish better maintenance of the hospitals. This autonomy improved the managerial quality of the hospitals and consequently reduced the level of government interference in public health initiatives (Anand, Peter and Sen 2000).
Nonetheless, the nature of hospital autonomy should be understood to operate within certain confines. The main framework for autonomy is the decision-making framework of the hospitals and their policy making divisions. The concept of autonomy is normally analyzed from a ‘zero’ to ‘one’ continuum where it is established that, a lack of autonomy is a zero and a decentralized system of hospital governance (autonomous) is one (Anand, Peter and Sen 2000). The main problem observed (from a lack of autonomy within various hospitals) is the fact that, the government’s role is heavily intrusive on hospital operations (Anand, Peter and Sen 2000). For instance, governments come up with hospital goals and formulate a demand for its expectations. This happens despite the fact that, hospitals are more experienced in healthcare matters. Hospitals know how to handle patients, public health and other pertinent matters regarding the same. Several healthcare institutions in various countries therefore experience varying levels of autonomy, but across many volumes of literatures studying the impact of hospital autonomy in the delivery of public health services, it is identified that autonomy greatly supplements the availability of quality public health services (Anand, Peter and Sen 2000).
Conclusion
Though public health practitioners are not often faced with ethical concerns (unlike medical practitioners), there is going to be an increased awareness of ethical concerns when implementing public health initiatives (in future). This is true because public health is slowly falling under the increased awareness of personal autonomy. Public health officials are therefore likely to be more aware of this fact whenever they intend to undertake any public health initiative. This is true because they are forced to respect individual autonomy, and in the same manner, assess the impact that their public health initiatives have on individuals. The increased awareness of personal autonomy is likely to have a resultant impact on individuals and their own health. This is a crucial element of public health because public health is supposed to guarantee individual health.
However, this paper identifies that personal autonomy in public health is not going to be unchecked. There is going to be a strong pressure on individuals to conform to the economic and legal pressures of personal autonomy as they practice their freedom. This means that as people practice personal freedom, they are not supposed to infringe on the rights of others and they should also do so within the confines of their economic abilities. For instance, people have the freedom to smoke but they should be aware that such an act has its own costs, including high insurance premiums and not to mention the high risks of death or illnesses. However, there needs to be more focus on the role which people play by being part of a wider society and practicing individual autonomy in the wake of social responsibility. This analysis probably provides a middle-ground to the balance that needs to be achieved between social responsibility and individual autonomy.
Another crucial concept to be included in the analysis of individual autonomy and public health is the contribution of the community as a central player in public health. This is true because in the administration of public health initiatives, it is impossible to ignore the community. In the past, communities were often perceived to be targets of public health initiatives but this paper notes that they will be more pivotal in the future. This is true because they play a crucial role in the determination of individual autonomy, but more importantly, they will no longer be passive participants in public health initiatives (but rather, active consumers). This fact is ascertained by a leading Bioethicist, Daniel Callahan who says
“We will not, I believe, be able to work out the problems of our health care system unless we shift our priorities and bias from an individual-centered to a community-centered view of health and human welfare. We cannot, and ought not to give up a respect for individual needs and dignity, but we can place them within a social perspective and allow that to color our understanding. At present, we ordinarily begin by asking just what it is which individuals need for their good health; if there are communal concerns, they are put in a subordinate position. It is the latter that must act as restraint upon the former, not the other way around as at present” (Anand, Peter and Sen 2000, p. 34).
Since communities are bound to be at the centre of the next frontier in implementing public health initiatives, they should therefore also be accorded the same level of autonomy which is given to individuals. Despite the tremendous progress made by public health (such as disease control and eradication), there should be more emphasis made to establish if public health is indeed observing individual or community autonomy.
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