Under the influence of concerns about sustainability, health system reforms have targeted institutional designs and have overlooked the role of socio-political factors like solidarity—a concept that is generally assumed to underpin the redistributive health system. The purpose of this research is to investigate users’ perceptions of the National Health Insurance as a system, their senses of solidarity and their views on the sustainability of the system in Taiwan. Using the descriptive ethics approach, qualitative in-depth interviews were conducted with typical case (...) sampling of 17 participants in the Taipei Metropolitan. The framework approach was used to analyze the interview transcripts. The research finds that despite great differences between users’ perceptions of the NHI, most users could share a notion of mutual relationship among each other. Three types of reasons are used to justify the obligations of mutual aid imposed by the NHI. These reasons are embedded within divergent conceptions of solidarity. The research also finds that government’s performance, the stability of decision-making and users’ personal experiences engaging with the system are important conditions for the users’ supportive attitude toward the system. Solidarity is a plausible concept in sustaining a non-Western social health insurance such as Taiwan’s NHI. (shrink)

The article propounds a justification of public health interventionism grounded on personal health as an intermediate human end in the ethical domain, on an interpretation of Aristotle. This goes beyond the position taken by some liberals that health should be understood as a prudential good alone. A second, but independent, argument is advanced in the domain of the political, namely, that population health can be justified as a political value in its own right as a primary social good, following an (...) interpretation of John Rawls’s evolved understanding of such goods in his later works. The article sets the scene for these positions by highlighting how liberal theories focusing on freedom as non-interference, or making the harm principle the basis of legitimate public health interventions, undercut the capacity of the state to actively promote population health. The article points to theoretical resources on legitimacy and liberty—the ‘salient coordinator account’ of authority and freedom as non-domination—that may help avoid this risk. The role of reflective equilibrium incorporating incompletely theorized mid-level principles is emphasized to ensure that interventions are soundly justified. The application of these principles would ensure that interventions do not exceed the proper moral/political boundaries limiting the role of government. (shrink)

Indoor smoking bans in public places is usually held as a simple and straightforward example of the application of the harm principle in public health. However, implementing indoor smoking bans in mental health centres is difficult because of the potential neurological and social benefits of smoking for persons with schizophrenia, as suggested by some empirical studies. In this article, the ethical challenges related to smoking bans in mental health centres as justified by the harm principle are explored. Particular attention is (...) given to the case of R v. Nottinghamshire Healthcare NHS Trust . The article concludes by arguing that the possible benefits of smoking for persons with schizophrenia creates a rightful interest that cannot be ignored even if one applies the harm principle to protect others from the negative effects of second-hand smoke. Applying the harm principle in the case of smoking bans in mental health centres requires protecting the interest of persons with schizophrenia to smoke via the value of reciprocity. (shrink)

This paper defends a distinctly liberal approach to public health ethics and replies to possible objections. In particular, I look at a set of recent proposals aiming to revise and expand liberalism in light of public health's rationale and epidemiological findings. I argue that they fail to provide a sociologically informed version of liberalism. Instead, they rest on an implicit normative premise about the value of health, which I show to be invalid. I then make explicit the unobvious, republican background (...) of these proposals. Finally, I expand on the liberal understanding of freedom as non-interference and show its advantages over the republican alternative of freedom as non-domination within the context of public health. The views of freedom I discuss in the paper do not overlap with the classical distinction between negative and positive freedom. In addition, my account differentiates the concepts of freedom and autonomy and does not rule out substantive accounts of the latter. Nor does it confine political liberalism to an essentially procedural form. (shrink)

Many legal scholars well recognize that, in some instances, support for a law or policy may be primarily because of its expressive function, i.e. the statements it makes about underlying values. In these cases, the expressive content of a law or policy may actually overshadow its central purpose. Examples of this phenomenon, according to Cass Sunstein, include, for example, regulations against hate speech in the USA. He suggests that achieving the consequence (prohibiting hateful speech against certain groups) may not be (...) the real focus (central purpose) of the law. Rather, the real focus is on the social meaning of these regulations—that bigotry is unacceptable in a liberal society. In this way, a particular law or policy can operate on many levels—while aiming to achieve a particular objective or behavior, it can also be a valuable tool for achieving other important social goals through its expressive function. This article applies this insight to the realm of public health policy, with particular attention to the case of pandemic planning, and suggests that public health policy and its overall goals may be well-served by deliberate regard for, and appropriate utilization of, the expressive function. (shrink)

Some theorists, worried about liberalism’s potential as a foundation for public health ethics, suggest that republicanism provides a better background of justification for public health policies, interventions, etc. In this article, this suggestion is put to the test, and it is argued that (i) contemporary (civic) republicanism and liberalism are not nearly as opposed as it is sometimes suggested, and that (ii) the kind of republicanism which one leading scholar in the field, Bruce Jennings, as an alternative to liberalism, does (...) not reflect the contemporary understanding of republicanism as held by, e.g. Phillip Pettit et al. (shrink)

For over 100 years, the field of contemporary public health has existed to improve the health of communities and populations. As public health practitioners conduct their work – be it focused on preventing transmission of infectious diseases, or prevention of injury, or prevention of and cures for chronic conditions – ethical dimensions arise. Borrowing heavily from the ethical tools developed for research ethics and bioethics, the nascent field of public health ethics soon began to feel the limits of the clinical (...) model and began creating different frameworks to guide its ethical challenges. Several public health ethics frameworks have been introduced since the late 1990s, ranging from extensions of principle-based models to human rights and social justice perspectives to those based on political philosophy. None has coalesced as the framework of choice in the discipline of public health. This paper examines several of the most-known frameworks of public health ethics for their common theoretical underpinnings and values, and suggests next steps toward the formulation of a single framework. (shrink)

Public health ethics is a nascent field, emerging over the past decade as an applied field merging concepts of clinical and research ethics. Because the “patient” in public health is the population rather than the individual, existing principles might be weighted differently, or there might be different ethical principles to consider. This paper reviewed the evolution of public health ethics, the use of bioethics as its model, and the proposed frameworks for public health ethics through 2010. Review of 13 major (...) public health ethics frameworks published over the past 15 years yields a wide variety of theoretical approaches, some similar foundational values, and a few similar operating principles. Coming to a consensus on the reach, purpose, and ends of public health is necessary if we are to agree on what ethical underpinnings drive us, what foundational values bring us to these underpinnings, and what operating principles practitioners must implement to make ethical decisions. If public health is distinct enough from clinical medicine to warrant its own set of ethical and philosophical underpinnings, then a decision must be made as to whether a single approach is warranted or we can tolerate a variety of equal but different perspectives. (shrink)

Ethical considerations from both the clinical and public health perspectives have been used to examine whether it is ethically permissible to mandate the seasonal influenza vaccine for healthcare workers (HCWs). Both frameworks have resulted in arguments for and against the requirement. Neither perspective resolves the question fully. By adding components of justice to the argument, I seek to provide a more fulsome ethical defence for requiring seasonal influenza immunisation for HCWs. Two critical components of a just society support requiring vaccination: (...) fairness of opportunity and the obligation to follow democratically formulated rules. The fairness of opportunity is informed by Rawls’ two principles of justice. The obligation to follow democratically formulated rules allows us to focus simultaneously on freedom, plurality and solidarity. Justice requires equitable participation in and benefit from cooperative schemes to gain or profit socially as individuals and as a community. And to be just, HCW immunisation exemptions should be limited to medical contraindications only. In addition to the HCWs fiduciary duty to do what is best for the patient and the public health duty to protect the community with effective and minimally intrusive interventions, HCWs are members of a just society in which all members have an obligation to participate equitably in order to partake in the benefits of membership. (shrink)

This article offers some general criticisms of the idea that any political theory can legitimate public health interventions, and then some particular criticisms of Civic Republicanism as a political theory for public health. Civic Republicanism, I argue, legitimizes liberty-infringing public health interventions by demanding high levels of civic engagement in framing and reviewing them; to demand such engagement in pursuit of such a baseline value as health will leave insufficient civic energy for the pursuit of higher values.

In the biomedical and behavioral sciences, it is widely recognized that researchers conducting studies involving human participants must respect the autonomy of research subjects. There is significant debate in the clinical research ethics and bioethics literatures about what it means for an individual to be autonomous. According to proponents of the Liberal Conception of Autonomy, an autonomous person is an agent who has interests and opinions and the capacity to deliberate about them. In contrast, proponents of the Relational Conception of (...) Autonomy argue that because humans are social creatures, autonomy is a relational concept and ought to be recognized as such by medical professionals. In this article, I argue that the LCA/RCA debate is flawed, and that the notion of freedom as non-domination, rather than autonomy, ought to be adopted for biomedical research ethics policies regarding informed consent and research agenda-setting. I then argue that this view of freedom should also be adopted... (shrink)

The further development of public health ethics will be assisted by a more direct engagement with political theory. In this way, the moral vocabulary of the liberal tradition should be supplemented—but not supplanted—by different conceptual and normative resources available from other traditions of political and social thought. This article discusses four lines of further development that the normative conceptual discourse of public health ethics might take. The relational turn. The implications for public health ethics of the new ‘ecological’ or ‘relational’ (...) interpretation that is emerging for concepts such as agency, self-identity, autonomy, liberty and justice. Governing the health commons. The framework of collective action problems is giving way to notions of democratic governance and management of common resources. The concept of membership. Membership is specified by the notions of equal respect and parity of voice and agency. The concept of mutuality. Mutuality is specified by the notions of interdependent concern and care. (shrink)

Public health involves the use of power to change institutions and redistribute resources and deliberately to shape individual thought and behavior. This requires normative legitimation and demands ethical critique. This article explores concepts that are vital to public health ethics, but have been relatively neglected. These are membership, solidarity and the concept of place. The article argues that the practice of public health should recognize the equal rights of membership in communities of health justice. Public health should also rely on (...) a sense of obligation and mutual aid in a world of shared vulnerability and reciprocal recognition. Finally, public health achieves its goals not merely—and perhaps not most fundamentally—through information and altering the logical ratiocination of individuals or groups, but rather through the reformation of sense and sensibility. (shrink)

This article contributes to philosophical reflections on public health law by drawing on virtue jurisprudence, which rests on the straightforward observation that a political community and its laws will inevitably shape the character of its officials and subjects, and that an excellent character is indispensable to fulfilment. Thus, the law is properly set to encourage virtue and discourage vice. This opens a new perspective onto the ultimate purpose of public health law that is human flourishing. The means of pursuing this (...) end is to entrust public health powers to officials to virtuously serve the common good, of which population health is one of its most important constituents, within the bounds of the law of the land. This article calls for the adoption of a Prudent Public Health Official standard into the law, in order to cultivate prudent, just, courageous and temperate characters in officialdom. Interestingly, this standard already chimes with certain pre-existing core principles of public health judicial doctrine in the USA, the European Union and the UK. (shrink)

Value judgements in research and political decision-making that exclude evidence for the social determinants of suicide suggest that evidence is not sufficient on its own to guide policy and practice, and that there is a lack of conceptual clarity with regard to decisions relating to the prioritization of problems, the allocation of resources, the translation of research into practice, as well as questions of responsibility for suicide prevention. In this work I seek to broaden conventional ethical debate about suicide through (...) the use of public health ethics frameworks. I argue that despite espousing a public health approach, current suicide prevention strategies are based largely on individual-level theorizing. This emphasis on the individual works to responsibilize individuals and communities for suicide prevention and directs attention away from public policy and systemic inequities. Given continued high rates of suicide, especially among disadvantaged social groups and communities, comprehensive government action is required to address the social and political determinants of suicide. Normative justification for action in realizing these ends is critical. I conclude by proposing one practicable form of action to make values and value judgements in suicide prevention explicit so that alternative forms of ethical and political recognition and responsibility are acknowledged. (shrink)

Reproductive genetic carrier screening is increasingly being offered more widely, including to people with no family history or otherwise elevated chance of having a baby with a genetic condition. There are valid reasons to reject a prevention-focused public health ethics approach to such screening programs. Rejecting the prevention paradigm in this context has led to an emphasis on more individually-focused values of freedom of choice and fostering reproductive autonomy in RCS. We argue, however, that population-wide RCS has sufficient features in (...) common with other public health screening programs that it becomes important also to attend to its public health implications. Not doing so constitutes a failure to address the social conditions that significantly affect people’s capacity to exercise their reproductive autonomy. We discuss how a public health ethics approach to RCS is broader in focus than prevention. We also show that additional values inherent to ethical public health—such as equity and solidarity—are essential to underpin and inform the aims and implementation of reproductive carrier screening programs. (shrink)

oise Baylis, 1234 Le Marchant Street, Halifax, Nova Scotia, Canada B3H 3P7. Tel.: (902)-494–2873; Fax: (902)-494-2924; Email: francoise.baylis{at}dal.ca ' + u + '@' + d + ' '//--> . Abstract Recently, there has been a growing interest in public health and public health ethics. Much of this interest has been tied to efforts to draw up national and international plans to deal with a global pandemic. It is common for these plans to state the importance of drawing upon a well-developed (...) ethics framework and we argue that this framework should reflect the values and insights of feminist relational theory. More specifically, we argue that pandemic planning must be squarely situated in the larger realm of public health and that an ethics framework for public health will be one that recognizes the need to pay particular attention to the vulnerability of subpopulations lacking in social and economic power. We propose an ethics framework for public health that builds on the notions of relational personhood (including relational autonomy and social justice) and relational solidarity. In this way, we aim for a public health ethics that, as appropriate, promotes the public interest and the common good. CiteULike Connotea Del.icio.us What's this? (shrink)

The idea that healthcare should become more person-centred is extremely influential. By using recent English policy developments as a case study, this article aims to critically analyse an important element of person-centred care, namely, the belief that to treat patients as persons is to think that care should be ‘co-produced’ by formal healthcare providers and patients together with unpaid carers and voluntary organizations. I draw on insights from political philosophy to highlight overlooked tensions between co-production and values like equality and (...) liberty. Regarding equality, I argue that co-production compounds both problems of gender inequality in the distribution of care labour and the challenges associated with securing equal access to care. Turning to liberty, I identify important commonalities between co-production and republicanism in political philosophy, given their shared insistence on common citizens’ civic virtue. Then, I use against co-production some liberal arguments against republicanism, to highlight a problem of over-demandingness. In bringing my argument to a close, however, I wish to caution against hastily rejecting co-production as a policy programme. (shrink)

In this paper I engage with the notion that Covid-19 can be seen as the ‘great equalizer’, in virtue of the widespread sense of uncertainty it has caused and the fact that it has forced us to recognize our shared human fragility. Against the view that Covid-19 is the ‘great equalizer’, I argue that, on the contrary, the pandemic reflects existing vulnerabilities and, in many cases, exacerbates them. I do so by offering first a definition of both ontological and relational (...) vulnerability and discussing some important ethical and political dimensions of vulnerability in conditions of uncertainty. I then claim that understanding vulnerability in both ontological and relational terms allows us to see the differential impact of the pandemic on differently situated individuals. More specifically, I argue that vulnerability in conditions of uncertainty can threaten individuals’ sense of self, and thus their autonomy – both understood in relational terms. I consider what kind of response human vulnerability in times of crisis calls for. In particular, I maintain that a promising way to counteract uncertainty would be to adopt a solidaristic approach to public health, based on an understanding of solidarity as a relational concept. In other words, I argue that it is through solidarity that individuals’ vulnerabilities can be mitigated, and their autonomy promoted, even during the most uncertain times. I finally discuss two objections that could be raised against the solidaristic approach defended in my paper. First, the approach may fail to find the support of individuals who are unwilling to care for others when their own interests are under threat. Second, there might be those who deny that the virus constitutes a serious enough threat to warrant or justify the restrictions on individual freedoms imposed by governments in the name of solidarity. I conclude by arguing that while a commitment to solidarity can be easily undermined by scepticism towards political and other authorities, and by the failures of those authorities themselves, it is paramount that societies strive for it as the best means to preserve individuals’ health, autonomy, and well-being. (shrink)