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Journal of Public Health Medicine                                                                                     Vol....
T HE VIRTUOUS PUBLIC HEALTH PHYSICIAN                                                      49

surprising, when the speci...
50                                          JOURNAL OF PUBL IC HEALTH MEDICINE

improvements that occurred. Indeed, Payne...
T HE VIRTUOUS PUBLIC HEALTH PHYSICIAN                                                       51

little book, reproduced f...
52                                         JOURNAL OF PUBL IC HEALTH MEDICINE

of health is another example of the virtue...
T HE VIRTUOUS PUBLIC HEALTH PHYSICIAN                                                                 53

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The virtuous public health physician


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  1. 1. Journal of Public Health Medicine Vol. 22, No. 1, pp. 48–53 Printed in Great Britain For debate 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
  2. 2. 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
  3. 3. 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 Virtue ethics 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
  4. 4. 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
  5. 5. 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 organizations are dismissed, even when later shown to be 1 Labisch A. A history of public health – history in public health. J Soc right.50 In the last 20 years constant reorganization of the Social Hist Med 1998; 11: 9. National Health Service management structures has created 2 Royal College of Physicians. Research based on archived information many opportunities for conscientious public health physicians and samples. Recommendations from the Royal College of Physicians to be quietly removed, without the need for crude dismissal. Committee on ethical issues in medicine. J R Coll Phys London 1999; 33: 264–266. Both the Faculty and the wider medical profession seem to 3 Percival T. Medical ethics. London: J. Johnson, 1803. have had only limited success in helping colleagues victimized in this way. 4 Shortell SM, Waters TM, Clarke KWB, Budetti PP. Physicians as double agents. JAMA 1998; 280: 1102–1108. The virtuous public health physician rejects single explana- 5 Charlton BG. Public health medicine – a different kind of ethics. J R tory causes for complex social problems. Like the quackery of Soc Med 1993; 86: 194–195. the 18th century, fundamentalist religious sects and the Nazi 6 Stone DH, Stewart S. Screening and the new genetics: a public health state, single explanatory causes appear to offer oversimplified perspective on the ethical debate. J Publ Hlth Med 1996; 18: 3–5. solutions for what are, in fact, multifactorial problems. It was 7 Chadwick R, Levitt M. EUROSCREEN, ethical and philosophical the wholesale adoption of misguided racial theories that led issues of genetic screening in Europe. J R Coll Phys London 1996; 30: to the German anti-tobacco campaign during the Nazi era.51 67–69. Although the propaganda campaign itself miserably failed, a 8 Rigby M. Keeping confidence in confidentiality: linking ethics, combination of a number of other factors did result in lower efficacy and opportunity in health care computing. Paper presented at a
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