The virtuous public health physicianDocument Transcript
Journal of Public Health Medicine Vol. 22, No. 1, pp. 48–53
Printed in Great Britain
The virtuous public health physician
J. Stuart Horner
Summary found wanting. Thus the profession was severely critical of the
breach in patient conﬁdentiality resulting from the circulation
This paper argues that although public health physicians
have shown interest in ethical dilemmas relating to speciﬁc
of paediatric information about individual patients even though
problems within the specialty, few have addressed the it was intended to help school medical ofﬁcers advise on the
central ethical dilemma in public health, namely the conﬂict educational implications. It also roundly rejected the proposed
between the rights of the individual and the responsibilities exemption from ethical review of epidemiological research.
of society for all its members. The paper reviews a number Practitioners in the specialty have been reluctant to acknowl-
of public health programmes, where different approaches
have been taken to this central dilemma. It then examines a
edge (because it is too uncomfortable) the conﬂict in public
number of schools of ethics, in an attempt to resolve the health, which results from the necessity for them to act as what
problem. Of these, only virtue ethics, perhaps supported by Shortell et al.4 call ‘double agents’. They believe that this
the insights of feminism and the ethics of care, appear to help challenge ‘must motivate appropriate physician behaviour in a
with an irreconcilable conﬂict. The paper then makes an way that acknowledges professional principles and peer respect,
attempt to apply the concept of virtue ethics in public health
medicine and to answer the question, ‘what would a virtuous
while at the same time meeting the needs of patients, purchasers
public health physician look like?’ Finally, it lists some of the and other external groups’.4
consequences of such an approach. A number of public health physicians have addressed speci-
Keywords: public health ethics, virtue ethics, utilitarianism, ﬁc public health problems. Charlton5 has argued that although
autonomy the clinical imperative that ‘something must be done’ is essen-
tial to the clinical encounter, it must not be adopted by public
health. He calls upon public health professionals to resist
Introduction ‘the constant temptation for government to be seen to be ‘‘doing
something’’ to tackle illness and disease, by making public
In a presidential address to a conference in Liverpool in 1997, to health interventions despite lacking scientiﬁc evidence for
mark 150 years of public health in the city, Labisch stated efﬁcacy’. Stone and Stewart6 see a risk that future efforts to
that the problems of the ethics of public health measures are subject screening programmes to rational evaluation could be
‘hardly discussed’.1 Few would quarrel with this conclusion. undermined by the development of genetic carrier screening.
The Faculty of Public Health Medicine is represented on the Chadwick and Levitt7 have reported on a European wide colla-
Committee for Ethical Issues in Medicine at the London Royal boration to investigate the ethical and philosophical issues
College of Physicians, but does not seem to have used this that arise with the development of new genetic technologies.
privileged position to elucidate the central dilemma of ethics Rigby,8 speaking at the height of the dispute about the
in public health. Indeed, one public health physician sought to conﬁdentiality of medical records, stressed that although ‘new
use the committee to exempt epidemiological research from the technical opportunities often need new policies and controls . . .
usual ethical review procedures.2 this has not had sufﬁcient attention’. In a previous paper,9 I
That incident illustrates an important principle enunciated reviewed the subject from a historical perspective, in the light
by Thomas Percival in 1803.3 He argued that such ethical of criticisms that public health practitioners were not taking
matters should be resolved by the whole ‘Faculty’, not in the ethical issues sufﬁciently seriously.10
narrow sense of a modern specialty or geographical area, but This apparent lack of interest in the central ethical dilemma
of the members of the medical profession regarded as one within the specialty by most public health practitioners is
body. It is perhaps at this point that the British Medical
Association has had an important contribution to make, as Centre for Professional Ethics, University of Central Lancashire,
public health physicians have tested their accepted practice Preston PR1 2HE.
against that of the profession as a whole and, sadly, have been J. Stuart Horner, Visiting Professor in Medical Ethics
Faculty of Public Health Medicine 2000
T HE VIRTUOUS PUBLIC HEALTH PHYSICIAN 49
surprising, when the specialty has held the chairmanship of the the expense of some individuals, as a result of unnecessary
Medical Ethics Committee of the British Medical Association anxiety, stigma, false reassurance or side effects from the
for 15 of the last 17 years. Just 10 years ago the section on procedure itself. In a perceptive paper, Clarke18 concludes that
public health in the handbook11 merely referred to the need genetic counsellors can never be totally objective in the options
for practitioners to enjoy the right of free speech to the they present to individuals. A population and public policy
communities they served and to the need for conﬁdentiality. By dimension will inevitably creep into the advice they offer. Once
1993, however, an enlarged edition12 had begun to address the again, the overall need of the population group interferes with
need to balance individual and community needs. the unambiguous autonomy of the individual.
The major problem is that of resource allocation. Treatment
that might beneﬁt the individual may have to be sacriﬁced to
The basic ethical dilemma
the overall needs of the population and the resources avail-
The central issue in public health ethics is to balance the able to it. Evidence-based medicine is a further example of the
intrinsic conﬂict between the rights of the individual on the one conﬂict between the needs of the individual and the interests
hand, and the responsibilities of society for the individuals of the wider community but creates a more subtle difﬁculty.
within it, on the other. I have argued elsewhere the nature of Charlton19 points out that ‘the implicit assumption that ‘‘noise’’,
this basic dilemma.13 Bloche,14 writing in a somewhat wider or random error, is the major obstacle to biological under-
context, states the need for doctors to ‘face conﬂicts between standing, is incorrect . . . the principal cause of variation
the ethic of undivided loyalty to patients [or individuals] and between individuals, is typically not random, but systematic
the pressure to use clinical methods and judgements for social error’. Thus, even large surveys and the process of meta-
purposes’. analysis may merely aggravate an unrecognized systematic
The dilemma manifests itself in many different ways. In error, resulting in a situation in which no single individual
infectious disease it is sometimes necessary to curtail the exactly conforms with the ﬁndings for the group of which s/he
autonomy of individual sufferers so as to control the risk of forms part.
spread to other individuals in that community. Virtuous public
health physicians carried out such duties extremely sensitively
Schools of ethics – can they help us?
for more than 100 years, although their actions were not always
appreciated by clinical colleagues. More recently, Harris and MacIntyre20 believes that we have lost the ability to discuss
Holm15 have questioned whether individuals have any moral moral problems of the kind I have outlined, in any coherent
obligation to prevent the spread of infectious disease to others. way, because we ‘lack any coherent rationally defensible
Although public health physicians will readily concur with their statement of a liberal individualistic point of view’. Although
conclusion that they do, the fact that this had to be argued out Stout21 considers this analysis to be far too pessimistic, the
from a moral perspective should alert public health physicians fact remains that we are faced with a multiplicity of ethical
to the very real nature of this central dilemma. How can the schools, all approaching the problem from a slightly different
interests of the community and the individual be reconciled? point of view. Public health is basically utilitarian in character.
Vaccination policies have careered wildly between compul- In a study of the perceptions of the objectives of genetic coun-
sion for smallpox vaccination on the one hand,16 to a position of selling, for example, public health physicians rated ‘facilita-
virtually complete autonomy in respect of diphtheria vaccina- ting decision making’ and risk assessment (both basically a
tion, before the Second World War. The pendulum now seems population perspective) as most important, whereas clinicians
to have settled at a position of gentle, but persistent coercion saw the provision of information and ‘support’ (an individual
on individual mothers. The decline in pertussis immunization in perspective) as the key objectives.22
the 1970s, following alarmist reports in the media, allowed the It is easy for practitioners, particularly young practitioners,
disease to reappear in epidemic proportions, placing far more to adopt utilitarian concepts almost unconsciously. Few public
children at risk of the disease, with its attendant complica- health physicians will not have heard of Jeremy Bentham, a
tions, than the potential but serious problems that the vaccine philosopher and law reformer, to whom we largely owe the
presented to a small minority of children. concept. As Ryan23 points out in his editorial preface, ‘none-
Similarly, in organ transplants, there are two ethical theless, it is Bentham’s brutally clear statement of ‘‘the greatest
dilemmas: ﬁrst, deciding which of two suitable patients is happiness principle’’ and Mill’s anxious reﬂection upon that
most ‘deserving’ for the single available organ, and secondly, theory which between them deﬁne utilitarianism’. It is no sur-
balancing both needs with the overall shortage of available prise that Edwin Chadwick was, for a time, Bentham’s secre-
donors. tary. Indeed, it could be argued that 19th-century utilitarian
Screening is a further example of this difﬁculty. Shickle moral theories were the driving force behind sanitary reform.
and Chadwick17 point out that a screening test cannot guarantee After all, virtually everyone beneﬁted, even the landlords
the detection of all ‘abnormal’ cases. Thus, although the overall and utility companies who, although losing an element of
health of the population may be improved, this may be done at autonomy, nevertheless themselves beneﬁted from the sanitary
50 JOURNAL OF PUBL IC HEALTH MEDICINE
improvements that occurred. Indeed, Payne24 believes that those oppressed by institutional structures. Such concepts make
utilitarianism still drives the whole medical project. He writes, feminism a natural ally of public health medicine, which has
‘since the method of medical practice and the current medical long advocated the needs of those living in poverty and those
ethic are identical, the promotion of individual moral con- suffering from social exclusion. As an oppressed group them-
siderations is extremely difﬁcult. The ‘‘ﬂow’’ is towards selves, women have experienced invisibility, the unheard voice
the greatest good for the greatest number.’ Darragh and and disempowerment. They can identify particularly with the
McCarrick25 make the interesting comment that ‘ironically experience of what William Booth called ‘the submerged
one reason that public health directives can take on the air tenth’ in Victorian society, who continue to be a group of
of moral imperatives, is that we live in a secular age . . . particular concern to public health practitioners.32 It is inter-
‘‘healthiness’’ has replaced ‘‘godliness’’ as a yardstick of esting that public health medicine contains a much higher
accomplishment and proper living’. proportion of women doctors than the profession as a whole.
Utilitarianism does not, however, resolve our basic Campbell et al.26 have suggested a different approach. They
dilemma. It simply justiﬁes us in giving supremacy to the believe that all health care workers share a common healing
needs of the community in the belief that this will beneﬁt ethos, arising from the intimate nature of the doctor–patient
most individuals. The minority of individuals who do not relationship, the need to provide information and consent, the
beneﬁt, and who may indeed be harmed, also deserve our moral imperatives of conﬁdentiality and truthfulness, and
consideration. Ultimately, the utilitarian is obliged to argue, if the collegial relationships within the medical profession. It is
a small number suffer so that the population group can prosper this commitment to caring that the public health physician
and ﬂourish, then so be it. To most doctors such an approach brings to the solution of the dilemma. Indeed, it is a cause of
not only sounds heartless, but conﬂicts with what Campbell the dilemma.
et al. have described as ‘the healing ethos’.26 Moreover, there Many of the ethical schools have therefore been found
have been plenty of historical examples in our own century wanting in the solution to our dilemma. One major school has
of the potential dangers to which such an approach may lead. still to be considered.
Pellagrino,27 reﬂecting on the corrupt health care system in the
former USSR, writes, ‘a morally responsive profession is an
indispensable safeguard for the sick against the statistical
morality of utilitarian politics, even in democracies’. Moreover, In 1998, Weed and McKeown33 concluded that ‘we can work
lest we should become complacent in our western liberal to create an environment which focuses attention on the virtues
tradition, he adds, ‘the integrity of medical ethics is not immune and professional conduct, as well as on our responsibility to
to corrosion, even in democratic societies. In democracies the public health’. In short, they proposed that public health
that corrosion will not be as stark as it was in Soviet Russia. It physicians should pursue virtue.
is apt to be more subtle and more likely to grow through legis- Virtue ethics has a long tradition, dating back to Aristotle.
lation of small increments of accommodation to expediency.’ He argued that virtue should be the mean between two opposing
Beauchamp and Childress28 have deﬁned four principles vices: it should, therefore, be the key to what we are seeking – a
that should guide all our ethical discussion. These are auto- balance between two equally unsatisfactory extremes. Aristotle
nomy, beneﬁcence, non-maleﬁcence and justice. This approach noted that whereas intellectual virtues are generally acquired
has been championed in the United Kingdom by Gillon, who by teaching, moral virtues come from habituation. We acquire
believes that it offers a common, basic, analytical framework virtue by practising virtuous acts.34 Thus, in seeking solutions
and moral language.29 However, despite the insistence by the to our dilemma, we shall seek to pursue virtue. Sometimes
original authors that each principle is of equal value, autonomy this will allow us give greater emphasis to community needs,
of the patient (frequently disregarding the autonomy of the whereas at other times we may emphasize the needs of indi-
practitioner) is becoming the dominant principle, although viduals. The concept of virtue ethics was readily taken up by
some voices have been raised in objection.30 This relentless the early Christian church, and Thomas Aquinas attempted to
drive towards autonomy takes us to the other end of our synthesize the philosophy of Aristotle and Augustine. Indeed,
dilemma, from that of utilitarianism and, as such, does not MacIntyre35 believes that the Thomist synthesis offers the best
resolve it. model to move ethical debate forward. We should therefore
Feminist writers believe that the pre-eminence given to each seek to address the central dilemma, by seeking to pursue
autonomy by ‘principlism’ and liberal ideology ‘preserves the virtue in the individual decisions that we all make. This
interests of the socially advantaged thereby constituting a conclusion may seem little more than a justiﬁcation for post-
bioethics for the privileged’.31 In consequence, feminist ethics, modernist thought. Such an interpretation, however, would be
which ‘seeks to understand and grasp the moral differences a travesty of the nature of virtue ethics. Although we each
between parties in moral conﬂict’,31 can assist us with our approach ethical problems from our own inherent value
central dilemma by providing helpful insights by its stress on systems, virtue ethics asserts that there are common virtues
the needs of vulnerable, disadvantaged groups and especially to which we can all aspire. Lord Hailsham,36 in a delightful
T HE VIRTUOUS PUBLIC HEALTH PHYSICIAN 51
little book, reproduced from his original handwritten manuscript Virtuous public health physicians will demonstrate the virtue
to which he made virtually no amendments, writes that, ‘the of friendliness in their social conduct. On many occasions they
primary thesis which I am seeking to support is that much of will be faced with trying and difﬁcult discussions, both with
the troubles of the present world . . . stems from a rejection of the managers and with clinicians. They will pursue disagreements
conviction that these value judgements have a real meaning and an in a friendly manner.
objective validity’. He goes on, ‘a common factor which unites all Aristotle’s virtue of liberality – as the mean between giving
value judgements in the ethical ﬁeld is a sense of responsibility to and getting – will be seen in the attitude of virtuous public
something external to ourselves’. We are therefore constantly health physicians towards the environment. Ecological aware-
seeking to pursue virtue, recognizing with Aristotle that, ness is not an optional extra but an integral part of the public
although it cannot be taught, it can be learned and practised. health ‘project’. Environmental medicine does not belong to a
We can now begin to sketch out what virtuous public health great and glorious past. It is becoming an increasingly urgent
physicians would look like. First, they are fully aware of this task for the present and future public health physician.
conﬂict between the needs of the individual and those of the Environmental degradation by man’s insatiable demand for
community and constantly try to address it. They will pursue more must be halted and reversed by the pursuit of a sustainable
Aristotle’s virtue of temperance, balancing the happiness of environment, giving back to it in return for receiving its bene-
the many with the pain of the few. There is genuine medical ﬁts. It is the global equivalent of the environmental degrada-
understanding of the problem presented, so that the healing tion seen in the United Kingdom in the 19th century. The
ethos can be applied. This is very different from a state ofﬁcial capacity for the environment to sustain itself despite severe
applying the cultural mores of the organization in which s/he insult is considerable but not inexhaustible. Virtuous public
happens to work. The approach will be overtly paternalistic, health physicians understand this and will join with ecologists
not because autonomy is rejected, but because autonomy is in promoting their aims.
part of the problem and cannot be relied upon to resolve the Similarly, virtuous public health physicians will be com-
dilemma. Kilner et al.37 note that the preoccupation with mitted to what Callahan38 calls ‘sustainable medicine’ recog-
‘autonomy’ owes much to Nietzsche and is really pandering to nizing that the reckless pursuit of individual health at all costs
human egoism. and even ‘health for all’ are an elusive mirage. The most that
Virtuous public health physicians will seek to be truthful. an equitable health care system can hope to deliver is to
In management truth has, sadly, become a relative value. It may promote the opportunity for everyone to live a natural lifespan
occasionally be necessary to remain silent, but deceit and rather than to waste valuable medical resources pursuing its
falsehood are incompatible with the primary role of the public inﬁnite extension or to medical juggling with the ultimate
health physician. They will also recognize that the organiza- cause of death. Good palliative care deserves a higher priority
tion does not have a total claim on the time and interests of than the unbridled pursuit of high-technology medicine.
medical professionals. Most controversially, virtuous public health physicians will
Virtuous public health physicians will seek to pursue demonstrate the virtue of courage, by constantly challenging
honour, both for themselves and for the quality of service that both managerial and medical orthodoxy. McCormick39 believes
they provide. Continuous professional development will not that ‘the degree of certainty should be much greater in matters
be an externally imposed discipline, but a spontaneous response of public health than in the conduct of the ordinary clinical
from within. They will be seeking constantly to improve indi- consultation’. Similarly, Skrabanek40 has questioned the use
vidual competence, both in themselves and among colleagues, of the consensus conference to agree the preferred method of
as well as promoting improved service quality in respect of treatment. Some are increasingly questioning the basic assump-
the services with which they are associated. Virtuous public tions of ‘the management myth’.41 Stewart questioned the
health physicians will display the virtue of righteous indig- vaccination programme against whooping cough.42 It is easy
nation at the ﬁnancial poverty that causes so much ill health to dismiss such ideas as the over-opinionated views of the
in society, and at the discrimination and disempowerment profession’s ‘mavericks’. Occasionally they are indeed just
that affects too many of the communities in which public health plain wrong, although history has a habit of providing some
physicians must practise. This righteous indignation will, how- vindication. In 1973, for example, the Director of the Public
ever, be tempered by the virtue of patience, which recognizes Health Laboratory Service reported that ‘much of the pertussis
that a serious assault on these problems is more likely to be vaccine in use for ﬁve or six years before 1968 was not very
achieved over a professional lifetime than in a few brief years effective’.43 The Medical Ofﬁcer of Health in Leicester was
of effort. Because of the long timescale through which public opposed to universal smallpox vaccination and his unorthodox
health is improved, virtuous public health physicians will be views undoubtedly delayed a diphtheria immunization pro-
modest in their career ambitions, preferring to identify with gramme in the city.44 Yet the strategy he adopted to control
their local communities, rather than moving on, like managers, smallpox was ultimately accepted by the World Health Organi-
to new jobs every few years, where past mistakes can be left zation during its eradication programme.45
behind. The approach to ‘problem families’ by medical ofﬁcers
52 JOURNAL OF PUBL IC HEALTH MEDICINE
of health is another example of the virtue of courage. Woﬁnden consumption than in other countries for at least 5 years after
provided the classical description.46 He sought to support the war.
such families in their own homes and, like a number of his
colleagues, Woﬁnden was closely involved with the Eugenics
Society and inﬂuenced by its prevailing views. Conclusion
Starkey47 considers that it was this unorthodox approach The central ethical issue in public health – the conﬂict between
to emerging social problems that led to the ﬁnal decline of the needs of the community and those of the individual – will
the medical ofﬁcer of health, following the transfer of such not go away, neither is it capable of solution. We can choose to
responsibilities to children’s departments in 1963. By a strange ignore it, as the literature suggests we have consistently done.
irony, however, social work orthodoxy is itself currently under We can engage in serious ethical debate, aware that few
challenge.48 Moreover, Welshman49 adds a perceptive post- ethical schools give us the solutions we seek. Above all, we
script to his conclusion that medical ofﬁcers of health were out should recognize the existence of the dilemma, teach new
of touch in addressing these problems. Thirty years after the recruits to recognize it and apply our personal value systems to
creation of vigorous social work departments to address these each new manifestation. Every proposed new public health
issues, he writes, that ‘contemporary developments . . . suggest intervention should be carefully evaluated for its ‘ethical
that reports of the death of the ‘‘problem family’’ may have been dimension’. Who will beneﬁt from this intervention? How
exaggerated’. These examples show that challenging the many are likely to be harmed and to which groups in society
orthodox is a necessary corollary for the virtuous public do they belong? What is the maximum level of personal
health physician. On occasions s/he will promote a changed autonomy that will still ensure the success of the community
orthodoxy and in others s/he will continue to challenge the programme? What discussion has taken place with those likely
perceived knowledge base. to be most affected and what were their reactions?
These are just some of the ethical issues to which such
Consequences interventions should be critically exposed. Only when all this
has been done and seen to be done, can public health physicians
The adoption of virtue ethics by public health physicians will make any claim to ethical behaviour, or to the pursuit of virtue.
have consequences. It will not be an easy road. Inevitably, it
will bring conﬂict with social leaders. It was for this reason
that for about 90 years medical ofﬁcers of health enjoyed some Acknowledgements
protection against arbitrary dismissal by their employers. Simi-
larly, although involvement in the management process The author, who was chairman of the Medical Ethics
enables public health physicians to make positive, beneﬁcial Committee of the British Medical Association from 1989 to
changes that promote the public health, it makes dissent on 1997, is most grateful to Professor Ruth Chadwick, Dr Bruce
ethical grounds to management policies, perhaps pursued for Charlton, Sir Alexander Macara and Dr Darren Shickle for
ﬁnancial reasons, far more difﬁcult. The virtuous public health their most helpful comments on earlier drafts of this paper.
physician may be required to sacriﬁce, or at least jeopardize,
a promising career on a matter of conscience. Most of those
prepared to speak out against the actions of their employing References
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