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Healthy RespectEthics in Health Care$

R. S. Downie, K. C. Calman, Ruth A. K. Schröck, and Malcolm Macnaughton

Print publication date: 1994

Print ISBN-13: 9780192624086

Published to Oxford Scholarship Online: September 2009

DOI: 10.1093/acprof:oso/9780192624086.001.0001

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PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2021. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use.  Subscriber: null; date: 22 January 2021

Public Health

Public Health

THE MORAL ISSUES

Chapter:
(p.207) Chapter 15 PUBLIC HEALTH
Source:
Healthy Respect
Author(s):

R. S. Downie

K. C. Calman

Publisher:
Oxford University Press
DOI:10.1093/acprof:oso/9780192624086.003.0016

Abstract and Keywords

There is an ethically important distinction between improving the health of the individual and that of the community. Particular issues arise, such as: vaccination, prevention, screening, and inequalities in health care. It is difficult to avoid a political dimension to public health issues and the question therefore arises as to the extent of legitimate medical intervention in political issues.

Keywords:   community, vaccination, screening, prevention, inequalities

1. INDIVIDUAL AND COMMUNITY

So far in this part of the book, we have been concerned with the individual, his or her rights, quality of life, etc. In health care, however, there is another dimension, that of the community. Important factors in this discussion include the resources available in the community and the differences between different geographical areas. They also include the important topics of information given to the public, the question of prevention, early diagnosis and screening. Some aspects related to the community will also be discussed in the chapter on economic issues. (Read also Chapter 6, sections 4, 5, 6.)

It should be clear that in some instances the health of the community may conflict with that of the individual. For example, if we take patients with infectious disease it is possible to make the case that such individuals should be isolated to protect the rest of the community. This may impinge on individual rights and could mean loss of employment and separation from the family. It may even mean treatment, even though the infected individual may apparently have no sign of the illness. For example, a patient who is a carrie of salmonella, an organism responsible for food poisoning, may be asymptomatic yet cause (p.208) considerable harm. Infective hepatitis as a source of potential harm to health care workers is well known. In more recent times the increase in the incidence of AIDS and HIV infection has raised even broader issues about the individual's health and that of the wider community. The possibility of infection of, for instance, dentists by patients with AIDS or hepatitis B is a real one, and there is a serious moral problem as to whether potentially infective patients should be identified and those caring for them informed. This could be regarded as putting the label ‘unclean’ on such individuals, but what of the risk to others? With this in mind the following questions might be asked.

  • How do you justify infringing the liberty of the individual to improve the health of others?

  • In what circumstances would you consider it necessary to isolate individuals from the community?

  • What restrictions, if any, would you place on individuals who are potentially a danger to the health of the community?

2. VACCINATION

Vaccination against specific diseases potentially confers great benefit on the community. On the other hand there is often a risk to the individual. It may be necessary therefore to ask for consent before vaccination is carried out. Read the section on consent (Chapter 18, section 3) and ask yourself:

  • Is consent required before vaccination?

  • Would your views change in the case of a common disease in a tropical country?

  • If consent is required, how much information would you give on the potential harmful effects? Would you include the mortality risks?

The topics of prevention and screening will be discussed in subsequent parts of this chapter.

(p.209) 3. ADVERTISING AND THE COMMUNITY

In a wider sense the messages which the public obtain from the media may be relevant to the health of the community. The most obvious example is cigarette smoking, where the evidence for a health hazard is overwhelming.

Alcohol advertising is a further example. In a world-wide sense there is the introduction of such habits into Third World countries which could be considered to be morally wrong. It is necessary to analyse carefully each of these situations before making moral judgements. Here are some questions you might ask yourself:

  • What are the arguments for and against cigarette advertising? Should it be allowed at sporting events?

  • Should advertising of alcoholic products be banned? If not, why not?

  • What steps would you take to influence the advertising of cigarettes in a Third World country?

4. HEALTH AND POLITICAL ISSUES

We have emphasized in this book the intimate relationship between the health worker as a professional and as an individual public citizen. Nothing highlights this better than health-related political issues where the doctor or nurse may be involved as an individual as well as a professional.

  • Take the issue of nuclear waste. How far should the professional be involved in such issues? As a doctor – or as an individual? Is it possible to separate the two?

  • Suppose that your children attend the local primary school, and there is some evidence that asbestos tiles have been used in the roofing. You, as a parent, but also as a professional, are asked to be part of the committee to take action on the matter. In what circumstances would you agree to take part? What would your role be – a professional, a parent, a public citizen?

(p.210) 5. SMOKING AND HEALTH

This topic provides a fascinating problem in relation to the health of the individual versus that of the community at large. There is very good evidence now that cigarette smoking has major adverse effects on health. Doctors and other professionals have a duty to point this out to patients and the public. However, there is a difficult question as to how hard the doctor should try to stop the patient from smoking without infringing individual freedom.

  • Consider the following courses of action and decide which of them would be reasonable, faced with a patient who smokes cigarettes.

    1. 1. Take no action at all.

    2. 2. Give general advice on the dangers of smoking.

    3. 3. Suggest attendance at an anti-smoking group.

    4. 4. Emphasize the impact on relatives of premature death related to smoking.

    5. 5. Say that you will not see the patient again unless smoking stops.

There is also evidence that cigarette smoking can be harmful to non-smokers who are exposed to cigarette smoke. The evidence comes from the incidence of illness in the children and spouses of smokers. Thus, while individuals have a right to smoke if they wish, there is a conflict if they interfere with the health of others. For example, in a hospital waiting room or day room area smoking is often permitted, yet non-smokers may suffer as a result.

  • How would you argue for and against cigarette smoking in communal hospital areas or other public spaces? Consider the rights of the individual versus the public at large.

Another argument can also be introduced at this stage, that of the economic effects of cigarette smoking. On the one hand there is a case for saying that the income from the taxing of cigarette purchase is very important in keeping the health service functioning. (p.211) On the other there is the cost to the health service of treating those patients who develop smoking related diseases. Further, there is the time lost from work because of illness which affects productivity.

  • Consider the arguments for and against reducing the income to the country by a successful campaign to stop smoking versus the reduction in the costs of treatment. Bear in mind the time-scale of this. There is an argument for increasing the tax on tobacco by a substantial amount. Is this fair to those who smoke and have a right to do so if they wish?

6. PREVENTION

Prevention is the key to the control of many illnesses and it is likely to become more important in the future. All health care professionals should have a role in prevention. In the prevention of illness several approaches may be used.

The first is an alteration of life-style, which would involve such factors as cigarette smoking, diet, and exercise. A second approach is to identify groups at high risk of developing a particular illness and to follow them closely and if necessary intervene. For example, there are a number of conditions such as ulcerative colitis and colonic polyps which are known to predispose to large bowel cancer. Having identified high-risk patients, doctors can monitor their progress. But several interesting moral questions arise including:

  • Should patients be informed that they are at high risk of developing a particular illness or disease?

  • Suppose that we know that there is a risk of a benign bowel polyp changing and becoming malignant, but the patient refuses an operation to remove it. What would you say?

A third approach is to use some form of vaccination procedure. This has been extremely successful in eliminating a range of previously very serious or fatal diseases. There is a (p.212) price however – that of the potential side-effects of the vaccination itself. Such side-effects are well recorded and can result in death or severe handicap. There comes a time, therefore, where decisions about the use of vaccine must be made.

  • Suppose that a vaccine for a common illness is available. The disease itself is minor in most patients but in some the disease can cause severe respiratory problems and there is an associated mortality. For the disease the morbidity is 1 in 10 000, the mortality is 1 in 50 000. The vaccine is also associated with morbidity and mortality. At what level do you think the use of the vaccine would be acceptable?

1 in 5000 morbidity 1 in 10 000 mortality

1 in 10 000 morbidity 1 in 50 000 mortality

1 in 20 000 morbidity 1 in 70 000 mortality

1 in 50 000 morbidity 1 in 100 000 mortality

7. SCREENING

Screening for disease seems to make sense. It makes possible the identification of the illness at an early stage, when treatment can be started with the hope of long-term cure. Predisposing factors can be identified and, if possible, eliminated. There are, however, several problems associated with screening programmes.

1. The false negative test. In this instance the test has been normal, but it has failed to pick up the disease. The patient may have been given the ‘all-clear’.

2. The false positive test. The test suggests that a particular disease is present, but subsequent investigation does not confirm this.

3. Ineffective treatment for the disease. This is a particular problem. The test is abnormal, but the treatment is ineffective.

4. High risk groups who do not come for screening. There is some evidence in cervical cancer that those at high risk belong (p.213) to those with a low socio-economic status, and such groups are the very ones who do not use screening services.

Particular examples of the problems associated with screening are exemplified by the following case-history.

As part of a routine screening survey a series of blood tests are performed on otherwise normal healthy individuals. One of these tests measures the serum level of gamma glutamyl transferase (GT), which may be elevated in conditions of abnormal liver function, notably related to alcoholic liver damage, but may in some cases be normal. Conversely, as in all blood tests, there is a ‘normal’ range and some ‘normal’ patients have levels which fall out of this range.

  • A 52-year-old, otherwise fit man who has been admitted for repair of an inguinal hernia, has a blood test which reports an elevated level of GT. The patient is not told about this but is asked to return and a second blood sample is taken, which confirms the elevated level. To investigate this fully would require a number of other tests, including a liver biopsy. Because the test is abnormal he is referred to you.

    1. 1. What would you tell the patient?

    2. 2. Would you investigate the patient further or would you wait a few months and repeat the test?

    3. 3. Would you raise the question of a history of excessive alcohol intake?

A similar sequence of events might occur in the diagnosis and management of hypertension. There is still controversy as to what level of elevated blood pressure requires treatment.

  • Suppose that you are a general practitioner who, on routine examination of a 35-year-old woman, detects an elevated blood pressure 140/100. She is otherwise asymptomatic. A repeat visit is arranged and the level is 140/95, still elevated a little. Would you tell the patient?

  • It is possible in this age-group that there is a remediable cause, but this would require hospital admission and investigation, (p.214) which might carry a morbidity or even a mortality. If you were the patient, and were given this information, would you wish further investigations to be done or would your choice be to live with the slightly elevated blood pressure?

8. PREDICTING HEALTH

As our understanding of the genetic basis of health and disease grows it will become possible to predict, in some instances, patterns of disease or illness. Already it is possible in the unborn child, using a series of tests, to predict sex, and in some cases outcome screening is already available for a number of diseases by testing in utero. This is likely to be increasingly available. While no intrinsically new moral problems are raised, a number of important topics need to be considered:

  • When testing the genetic profile of an individual, whose property is the result, and how may the information be disseminated?

  • As testing of the unborn child for genetic influences progresses, would you put limits on the process?

9. INEQUALITIES IN HEALTH CARE

It does not take a great deal of careful observation to note that some areas of the country are better served by health services than others. This may relate to specialist services or to community care. For example, one district may have a specialist renal dialysis service, but no hospice for the continuing care of the terminally ill. Another may have a community based diabetic service, but no cardiac surgery. Such inequalities have often grown up by chance, related to the interest of a particular professional group. These inequalities, however, do raise important moral issues as well as economic ones.

(p.215)

  • Do all members of the community have the right to have access to specialist services provided within the local area?

  • Should some services be centralized and not available locally?

  • What is the minimum which should be provided locally? – maternity care, child care, renal transplantation, radiotherapy, etc.?

This issue will be discussed further in Chapter 17.

10. CONCLUSION

From this brief review it can be seen that community aspects of health raise a number of important moral issues. In some cases it is not possible to separate the role of the professional from that of his role as a public citizen. Screening raises very general issues about truth-telling which were discussed in Chapter 10.