An example: how can autonomy be respected in health education?

Granted that autonomy is valuable and that it should be respected in health policies what does this mean for health education which is the corner stone of what public health authorities are supposed to do in a liberalist society? Gerald Dworkin has presented the following list of attitudes, norms and preferences which are usually associated with respect for autonomy in policy-making:

1. We have favourable attitudes towards those methods of influence which support the self-respect and dignity of those who are being influenced.

2. Methods of influence which are destructive of the ability to individuals to reflect rationally on their interests should not be used.

3. Methods should not be used which affect in fundamental ways the personal identity of individuals

4. Methods which rely essentially on deception, on keeping the agent in ignorance of relevant facts, are to be avoided.

5. Modes of influence which are not physically intrusive are preferable to those which are.

6. There will be some restrictions on the time in which the changes take place and the ability of the agent to resist the effects of various modes of influence.

7. We prefer methods of influence which work through the cognitive and affective structure of the agent, which require the active participation of the agent in producing the change, to those which short-circuit the desires and beliefs of the agent and make him a passive recipient of the changes.³⁹

Although DworkinÕs points are rather general, many of them can be employed almost directly to the assessment and redefinition of health education. The following practical guidelines, which are partly overlapping, are perhaps the most important that can be derived from DworkinÕs ideas:

1. Modes of health education that violate the autonomy of individuals should not be encouraged.

2. Self-evidently, health education should not involve punishment.

3. Modes of health-education that enhance the autonomy of individuals ought to be encouraged.

4. Health education should not be frightening or overly emotional, nor should it evoke feelings of guilt or build up undue pressures in the life-styles chosen by individuals.

5. Health education should be ideally to disseminate truthful information about the causes of ill health and the dangers confronting people at home, at the work place and elsewhere.

6. Since lying and deception are to be condemned, public health authorities should not conceal, or omit to inform people about, the good effects of life-styles which are regarded as unhealthy, for instance, the advantages of consuming moderate quantities of alcohol.⁴⁰ If all these norms are taken seriously, health education ceases to be a mechanical means to promote peopleÕs physical wellbeing, and becomes an autonomy-enhancing method of health policy. The best way to define this policy is to say that, instead of trying to make people healthy against their own wishes, health education should aim at making people aware of the conditions of their own health. Individuals cannot be legitimately forced into physical wellbeing regardless of their self-determined decisions, but they can, and should, be informed about the factors that are relevant to their health. The availability of the information can eventually lead to the improvement of the physical wellbeing of the population, but if it does, this should be treated as a bonus, not as the primary goal of health education.

In addition to face-to-face clinical paternalism and public health education, the populations of our societies are also subject to more delicate and far more extensive forms of possible intervention. These include laws regulations dangerous behaviour in everyday life, regulations concerning the manufacture, advertising, sale and consumption of drugs and intoxicating substances, and preventive medical and socio-political measures such as quarantines, vaccinations, and plumbing. In fact, a surprisingly large part of these regulations and activities are ethically unproblematic, either because there are good non-paternalistic grounds for upholding and approving them, or because their paternalism is, measured by the standards of freedom and autonomy, clearly legitimate or illegitimate. Quarantines and quarantine-like measures such as home arrest, electronic surveillance, compulsory hospitalization and imprisonment are justifiable, if they are justifiable, by an appeal to the potential harm inflicted on other people by carriers of communicable diseases.

In a liberal, egalitarian society there are many qualifications which reduce the ethical acceptability of isolation policies in real-life situations: the threat posed on others may be symbolic rather than concrete, the isolation can be comparable to imprisonment of a person who has never committed a crime, the identification of the ones to be isolated would sometimes require serious violations of civil liberties, and compulsory hospitalizations lack medical purpose when no actual cure is available. We should not forget either that elements of xenophobia, prejudice, moralism and misleading interpretation of probabilities may seriously endanger civil rights. Once again, the promotion of so-called general good Ð whatever it happens to be Ð is not the only ethical consideration when coercive policies are discussed in a liberal framework.

Liberal intuition in social and medical policies may lead to combining need-based positive claim-rights with the antipaternalistic, negative concept of liberty. This implies that individuals should be left free to make their own choices, provided that the consequences of their decisions are not likely to have a negative effect on the basic need-satisfaction of others.

In this model there is no assumption of other agents Ð be it the state, community, cultural leaders, religious teachers, being more knowledgeable than the individual themself regarding their life-style choices. No one is supposed to possess normative wisdom entitling them to paternalistic behaviour if and when we are talking of ordinary adult citizens. The prevailing premise is that human beings can and should be free even if their actions seem irrational to others. As I said earlier, what distinguishes welfare or egalitarian liberalism or liberal egalitarianism (whatever name we want to use) from libertarianism is that the former take peopleÕs needs fully into account in ethical and political decision-making.

Libertarians can happily live among people who suffer from easily curable diseases and injuries but those who have taken to egalitarian ideals, even in their individualistic forms, cannot. In health care policy-making liberal egalitarianism stands for an extensive system of public health care, accompanied with a zealous respect for the autonomy of patients and other users of the services. Democracy in this model means both concern for the well-being of the population and consideration towards the privacy and freedom of individuals. Respect for individuals should not be mistaken for unquestioning respect of group rights and group autonomy. The ideal of toleration and respect for peopleÕs values and beliefs does not mean that self-professed leaders can make, in the name of cultural, ethnic or cultural rights demands for special treatments or exempts in practices merely be reference to the fact that they represent a minority. Taking individual rights seriously is the only way to at least try to guarantee that all citizens are equal members of a democratic Ð and liberal Ð society.