Values in Preventive Medicine - Europe PMC

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that "[a]dopting a purely medical ap- proach is a way of dealing with the conse- quences of hypertension without un- settling the social order that generates.
Values in We know how lifestyle affects health, yet concern for preventing illness by promoting healthy lifestyles remains marginal in medical practice. Effective preventive strategies can raise daunting moral and political problems about the extent to which individual freedoms may be infringed, particularly on paternalistic grounds. Evaluative questions also arise about more specific matters, such as identifying risk and causal factors, determining what level of risk is acceptable, and deciding how compelling the evidence must be to take preventive action. Nous savons tous que le mode de vie influence la sante mais, en pratique, notre preoccupation a prevenir la maladie en favorisant des habitudes de vie saines demeure marginale. Les strategies preventives efficaces peuvent soulever des problemes moraux et politiques intimidants concernant les droits et libertes de l'individu, particulierement le paternalisme. Certains themes plus specifiques, comme l'identification des facteurs de risque et des facteurs etiologiques, la determination du niveau acceptable de risque et la decision de preciser jusqu"a quel point l'evidence doit etre contraignante avant d'agir preventivement, soulevent souvent des questions ethiques. (on Fam Physian 1992;38:321-327.

Preventive Medicine T7he hidden agenda BARRY HOFFMASTER, PHD

AUSAL CONNECTRONS BETWEEN

lifestyle and disease and illness have long been recognized. In 1755, Rousseau introduced a brief appraisal of the art of medicine by asking "whether there is any solid evidence to conclude that in Countries where this art is most neglected the average life span is shorter than in those where it is cultivated with the greatest care" and answering, "how could it be, if we inflict more ills on ourselves than Medicine can provide Remedies!"' Rousseau's enumeration of the social disadvantages and human frailties that contribute to ill health is striking in both its vividness and its current relevance. The extreme inequality in ways of Ife, the excess of idleness among some, the excess of work among others, the ease with which our appetites and our sensuality are aroused and satisfied, the excessively exotic dishes ofthe rich whichfill them with inflammatory humors and wrack them with indigestion, the badfood of the Poor which most ofthe time they do not even have and the want ofwhich leads them greedily to overburden their stomachs when they get the chance, the late nights, the excesses ofevegy kind, the immoderate transports of all the Passions, the fatigues and exhaustion of the Mind, the innumeraDr Hoffnaster is Director of the Westninster Institute for Ethiws and Human Values, is a Pnfessor in the Department of Philosophy, and is an Associate PNfessor in the Department of Family Medicine at the

Universip of tWestem Ontanio, London.

ble sorrows and pains that are experienced in every station of Ife and that constantly gnaw away at menl souls; such are thefatal guaranties that most of our ills are of our own making. ' An appreciation of the impact of lifestyle on health and illness long antedates Rousseau 's observations, however. In Airs Waters Places Hippocrates advises a physician arrivmng in an unfamiliar town to examine not only the local waters, winds, and geography, but to note the way of life that is pleasing to the inhabitants, in particular, "whether they are heavy drinkers, taking lunch, and inactive, or athletic, industrious, eating much and drinking little."2 Given that awareness of such causal links is as old as medicine itself, why has a concern for promoting healthy lifestyles remained marginal in the practice of medicine? A possible answer is that the demands of prevention are simply too exacting. Rousseau's solution, returning to "the simple, uniform and solitary way of life prescribed to us by Nature,"' does, indeed, seem unduly spare and unrealistic, but modern recommendations about diet and exercise are strikingly similar. Another possible explanation is that it is too psychologically and morally taxing to accord much weight to the loss or impairment of mere "statistical" lives.3 There are, however, two deeper explanations. One is that values and judgments about values permeate the activities of disease prevention and health promotion. Canadian Family Physician sOL 38:

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Conflicts inevitably arise among these diverse values, and resolving those conflicts requires judgments we are reluctant to make. In an intellectual climate that exalts

the subjectivity and relativity of values, some people lack the confidence to make any evaluative judgments whatsoever; they bury their timorousness in a principle of tolerance, a principle that, despite its own apparent grounding in subjectivity and relativity, takes on a remarkably objective and universal cast. Other people are uncomfortable making the value judgments needed to endorse specific preventive mechanisms. In a social, political, and legal climate that extols individual freedom and individual rights, it is difficult to justify infringing the liberty of persons, especially when doing so is supposed to be in their own self-interest. The second answer is that disease prevention and health promotion are founded in a biopsychosocial model of health. Although this model is central to family medicine, it is subservient to the biomedical model of disease that is largely responsible for the triumphs of hospital-based acute care and is inconsistent with the reductionist ethos of science. The influence of these factors notwithstanding, the marginal status of prevention in medical practice remains surprising because, in theory, the case for it is formidable. If one assumes that life and health are not intrinsically good, they are still good as means to a range of important human ends. Either way, preventing pain, disability, and premature death possesses substantial value. Moreover, the adage, "an ounce of prevention is worth a pound of cure," is hard to impugn, especially when the methods for averting disease are simple and inexpensive and when much illness cannot be cured but only ameliorated.4 WVhat, then, blemishes the theoretical attractiveness of disease prevention and health promotion? One reservation emanates from a change in the target of prevention. The most serious health problems now are chronic, noncontagious disease and infectious diseases (eg, hepatitis, AIDS) for which causal agents cannot easily and inexpensively be identified and successfully controlled. The triumphs of prevention include compulsory immunization programs 322

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for polio and smallpox; the construction of sewage treatment plants and water purification systems to eradicate cholera and typhoid; and the introduction of pasteurized milk to prevent tuberculosis and brucellosis, of vitamin D in milk to prevent rickets, and of iodized salt to prevent goiter. In such cases the benefits of acting are indisputable; the benefits are well-known to the public, partly because of the relatively short time between exposure and onset; and the benefits are easily and effectively attained, largely because the measures adopted allow little or no leeway for individual choice. In these situations the government has received a mandate to proceed, even if doing so might infringe the freedom of its citizens - as has been alleged, for instance, with fluoridation of water to prevent tooth decay. Chronic, noncontagious disease, however, is produced by complex sets of etiologic factors in which the habits and behaviors of people and the condition of the environment play an important role. Reducing the incidence of heart disease, stroke, and cancer, to cite three of the most prominent examples, requires extensive changes in lifestyle at both the indi-

vidual and social level. Inducing such changes, however, raises daunting problems with respect to personal motivation as well as moral and political problems concerning individual freedom. Education, because it is morally innocuous, is the most widely recommended strategy for trying to induce lifestyle changes. Providing information does not represent a threat to liberty or autonomy because individuals remain free to decide whether to act on this information. Unfortunately, though, people often fail to assimilate information, and they often lack the motivation or will power to do what they know they ought to do. Effective preventive efforts therefore have to go beyond mere education to affecting attitudes, desires, values, and decision making. A central moral issue is whether intrusions designed to influence people's perceptions of problems, decision-making processes, and motivation to act violate individual liberty or autonomy. There are two ways in which such intrusive action might be justified. Promoting public health can, on the one hand, be

regarded as fostering the common good. If so, to what extent may individual liberty be encroached to bring about the common good? But when the common good involves the prevention of harm to others - for example, reducing the risks associated with second-hand smoke from cigarettes - the case for restricting individual freedom is solid and straightforward. But when the common good involves bringing about some improvement in the condition of society, especially when it is amorphous or speculative, the moral case is much harder to sustain. Promoting public health can, on the other hand, be regarded as in the self-interest of the discrete individuals who comprise a community. Then the familiar problem of paternalism arises. To what extent may society impose its vision of what is in the best interest of its members upon those who do not share this vision? The answer that currently prevails is the one given by John Stuart Mill in 1859: "[t]he only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant."5 Because the notion of the common good has virtually disappeared from moral and political discourse, only a paternalistic justification for more intrusive preventive initiatives exists. How might the moral barrier it poses to intervention in the interest of prevention be removed? One strategy is to question the notion of autonomy upon which the charge of paternalism is predicated. A moral and political stance that is preoccupied with individual autonomy is atomistic and reductionist because it regards society as an aggregate of independent, self-contained, rational calculators - it transforms people into what one writer calls "evaluative Godlets."6 But portraying people as ideally rational agents abstracted from the societies and cultures in which they have been raised and in which they live ignores the profound and multifarious ways people are shaped by their social and cultural milieus and other environments.7 If there is no realm of pure freedom or autonomy - if,

that is, persons cannot be severed from their social connectedness and if the decisions they make are ineluctably influenced by external factors - then there is a moral opening for society to intervene with respect to choices that are not genuinely autonomous and to attempt to remould the social forces that prompt people to adopt harmful courses of action. This argument has been made for smoking, where the effects of advertising, peer pressure, parents who smoke, social and economic status, and the addictive power of cigarettes are regarded as undermining the freedom of decisions to start and to continue smoking. The conclusion drawn is that, because it is impossible to eliminate the influence of parents and peers, "intervention of the state to restrict or totally prohibit cigarette advertisements . . . is morally justified."8 Another difficulty is that the purely "self-regarding" behavior that is supposed to be immune from paternalistic intervention is hard to find. Is there any action that does not somehow impinge upon other people or society? The connection between individual behavior and social conditions sometimes appears tenuous, as, for example, when obesity is linked to the national fuel bill in the tUnited States with the intent of transforming obesity from a personal problem to a social problem.9 In many situations, however, it is genuinely hard to contend that the behavior of a person affects only and exclusively that person. Courts have upheld legislation that requires the wearing of motorcycle helmets, for instance, on the basis of a "public ward" theory that recognizes the cost of emergency services and hospital costs for accident victims as well as the prospect that they might become wards of the state. IO

The most insidious danger in the paternalistic objection to prevention, however, is that because autonomy is intimately tied to responsibility, individuals will come to be held overwhelmingly, if not exclusively, responsible for the deleterious outcomes of their decisions. "A common theme in preventive approaches is to emphasize self-responsibility,""i but stressing the accountability of the individual invites victimization. Perceiving problems in terms of individual "fault" is a convenient way Canadian Family Physician vOl. 38: Februay 1992 323

of deflecting attention from contributory social, political, and environmental causes. It has been suggested, for example, that hypertension is "in part, a disease of the modern industrialized world" and that " [a] dopting a purely medical approach is a way of dealing with the consequences of hypertension without unsettling the social order that generates conditions of risk for the disease."'2 The individualism fostered by prizing autonomy and self-determination could exacerbate the tendency to make people with problems scapegoats for an indifferent or hostile system. When one moves from such general concerns to specific ones, evaluative issues are equally pervasive and equally vexing. For what problems may preventive health measures be taken? When may these measures be taken? And how should the measures be formulated and implemented? Addressing the first question requires the determination of what constitutes a health problem. Is any condition or behavior that has a negative effect on health a health problem? Obesity, for example, is now viewed as a health problem because it is a risk factor for hypertension, diabetes, coronary artery disease, arthritis, and some cancers and because there is evidence of benefits from weight reduction for patients with diabetes, hypertension, and hypercholesterolemia.1' But where are the limits? While the prevention ofbehavioral and emotional disorders in children is a recognized mental health issue,14 what about the problems of child abuse and neglect and television violence? Are they essentially or even primarily health problems? And if so, what about homelessness and pollution? Is there any social disorder or social evil that cannot be brought within the compass of disease prevention and health promotion? Emphasizing the impact of these social problems on health enhances their seriousness, but at the same time, it contributes to the pro-

gressive medicalization of society. Determining when preventive measures are warranted also poses evaluative

questions. One concerns the stringency of the criteria for establishing risk and causal factors. Only the most intractable defenders of smoking would continue to deny 324 Canadian Family Physician VOL 38: Febmary 1992

that smoking plays a causal role in lung cancer, coronary heart disease, and chronic obstructive lung disease, yet uncertainty persists about the relationship between atherosclerosis and diet and activity.13 As well, an "apparent correlation" between cancer and consumption of large quantities of meat is not conclusive because "meat consumption tends to rise with standard of living, and something else that rises with the standard of living might be the cause of the cancer, or one of the causes."" Evaluative judgments are likewise involved in deciding what constitutes a risk and what level of risk is acceptable. Judgments about risks are made, wittingly or not, in a host of mundane contexts: "Many pleasurable actions - swimming, skiing, mountain-climbing, eating gourmet food - carry a risk to health or lifespan. How is the trade-off to be made between 'living life to the full' and 'living safely and long'?"" Risk assessments also pervade occupational and environmental health, for instance, in setting standards for the amount of lead in tap water. " And, as the example of hypertension makes clear, they are unavoidable in clinical medicine: "The decision by the health care professions to use a 90mm Hg cutoff of normality incorporates a significant normative premise: that is, above that level, the level of risk is substantial enough to warrant surveillance and/or treatment."'2 At times a risk assessment can be excruciating, as in deciding when to remove a child from its family. There is a report, typically horrific and heart-rending, of a 6-month-old infant, born to a drug-addicted couple in Switzerland, who was so badly beaten that she is now severely handicapped and blind. The problem faced by those handling this case was "the ethical one of taking a child away from her addict parents, or leaving the parents the chance that she might be a help in their rehabilitation process."'5 Once risk factors have been identified, another evaluative decision may have to be made because of the potentially harmful consequences of labelling people. It has been reported, for example, that labelling individuals as hypertensive can have an adverse impact on their psychological

well-being and marital functioning as well as on their work attendance and economic well-being. 16,17 In addition, preventive interventions need to be sensitive to circumstances and the values they embody. Because the potential benefits of prevention decrease as life expectancy shortens, smoking cessation programs, for example, are not as compelling for elderly persons. Deeply ingrained habits likely require more strenuous efforts to be eradicated; thus, elderly individuals would be assuming greater burdens to enjoy benefits of shorter duration. The call for health-promoting and disease-preventing behavioral changes in the elderly, therefore, needs to be tempered with consideration of how the quality of their lives would be affected. For all evaluative decisions in prevention, how compelling must the evidence be? The pressure of escalating health care costs is producing: growing impatience with the insistence on meeting all the canons ofscientific proofbefore taking public action. ... Whereas the use of randomized control trials i widely accepted as a necessagy step in eva luating new medications, health promotion and education are often taken as having sufficientface validity to require no more than cursoy evaluation, f

any.'3 Lowering the standards allows preventive initiatives to be implemented more quickly, but at the same time it makes the outcomes of those initiatives more uncertain. Interventions might turn out to be premature or even harmful because they are based on a simplistic understanding of the problem. More importantly, the very legitimacy of prevention could be threatened if preventive initiatives begin to look more like marketing techniques or become vehicles for pursuing personal moral and political agendas. 18 Once it has been decided that preventive measures are appropriate, the question of how to intervene remains to be settled. Should responsibility fall to the government; to non-profit, non-governmental organizations; to companies in the private sector; or to a combination of these? Or should responsibility be left to individuals - should it be, for instance, a matter on which family physicians would

counsel their patients? Should interventions aim at education and encouragement (for example, warning labels on tobacco products and alcoholic beverages and public service announcements about good nutrition on children's television shows'9), at introducing incentives (for example, lower insurance rates for safe drivers) or disincentives (for example, higher taxes on alcohol and tobacco), or at compulsion and coercion (for example, legislation requiring the use of seat belts and banning tobacco advertisements)? Answers to these questions depend, in part, on assessments of effectiveness. For example, it has become lucrative for general practitioners in middle-class areas of England to lecture patients about diet, exercise, and smoking, but little benefit is being realized because they tend to preach to the converted.20 The proposed remedy is to change the payment scheme so that general practitioners in deprived areas would earn more for holding health-promotion clinics. But evaluative issues are involved, too. Sexually transmitted diseases can cause female sterility, and the attempt to alleviate this problem produces controversial technologies, such as in vitro fertilization. The preferable course, in all respects, is prevention, but the only morally acceptable technique in such an intimate, private domain is education. Preventing sterility "can only be carried out through adequate information freely and fully available to those concerned: any form of constraint in matters such as the choice of methods of contraception is not possible."2' As this example demonstrates, there must be a moral fit between the nature of the problem to be prevented and the form of intervention adopted. Devising an appropriate intervention strategy depends on considerations of efficacy and ethics and, in some cases, on resolving a conflict between them. The practice of medicine is enmeshed in a socio-political context that determines its form and content, as well as its direction.22 Because that socio-political milieu is dominated by a scientific ethos congruent with the biomedical model of medicine, the cultural background of the practice of medicine is often invisible. But when the theoretical foundations of a Cnadian Family Physician VOL 38: February 1992 325

branch of medicine challenge the reigning scientific paradigm, as happens in family medicine and public health, the social and political dimensions ofthese areas become prominent, and that, in conjunction with their deviation from scientific orthodoxy and medical purity, serves to subordinate them. It has been pointed out, for example, that the benefits of simple and inexpensive education methods designed to reduce smoking during pregnancy and improve the diet of pregnant women far exceed the benefits derived from more costly efforts to prevent phenylketonuria. Yet it is the latter that prevails: "the one strategy is so highly valued that it would be unthinkable to withdraw screening for phenylketonuria and the other so undervalued that it is very difficult even to persuade an obstetrician to mention smoking or enquire about smoking habits."23 This hierarchy of values derives ultimately from a culture mantled by science. The prevailing model of science determines how problems are defined, what problems are regarded as most urgent, and where and how solutions to the salient problems are to be sought.

/77he reductionist biomedical model begins with organ physiologv and gross anatomy and moves progressively to the molecular level, seeking to identify disease in precise molecular terms and tofind equally precise molecular therapies. However the currentIv emergent and dominating societalproblems ofviolence, suicide, substance abuse, homelessness, and the prevention ofAIDS are problems ofpopulations, demography, and epidemiologv - areas not likely to seem academically relevant to traditional medical faculy. Confusion and conflict are certain to develop should such traditional, biomedically orientedfaculy perceive an inappropriately large proportion of scarce resources being directed away from molecular studies to what they regard as ultimately less productive activities.24 The global claim that preventive activities are "less productive" renders them peripheral and expendable. Yet supplementing, or perhaps even supplanting, the vision of medicine that generates this claim is an intimidating problem, one that is compounded by the vagueness of crucial notions, such as health and autonomy, and the need to address troubling evaluative questions. 326

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But even if these conceptual and evaluative issues were confronted, it is not clear how they could or should be settled. Calls for the community or society to decide are as unhelpful as they are commonplace. The more specific suggestion that the conflict between individual freedom and coercive preventive measures be resolved by a popular votc or referendum carries a superficial democratic appeal but is difficult to sustain in detail.'Disease prevention and health promotion will assume the prominence they now possess only in theory if medicine becomes less reductionist and society becomes less individualistic - both changes perhaps being forced by unrelenting economic pressures. WVere that to happen, the challenge then would be to design new institutional arrangements for resolving the medical and moral issues at the heart of attempts to improve the health of society.8 Rather than simply tinkering with existing social systems, however, the changes required would be radical. A "hard health path," one that "accepts the givens of our society and plans an illness-care system, which, for the most part, tries to patch people up and return them to the battle," and that relies on large institutions, technology, and expert technicians would have to be replaced by a "soft health path," one that "structures society so as to promote health," and thus requires fundamental changes in the energy, food and agriculture, employment, education, healthcare, and family and community sectors of society." That, however, is the bedrock lesson of prevention: "health, particularly from the preventive point of view, is to a large extent a matter for social policy U and social action."" Acknowledgment I thank 7T Freeman, G. 7T Swart, M. Yeo and the anonymous referees of Canadian Family Physician for their helpful criticisms in drafting this paper Requests for reprints to: Dr Bary Hoffmaster, Westminster Institute for Ethics and Human Values, 361 Wndermere Rd, London, ONN6G 2K3 References 1. Rousseau J-J. The first and second discourses and essay on the origin of languages. Gourevitch V, editor and trans. New York, NY: Harper & Row, 1986. 2. Hippocrates. Airs waters places. In: Jones WHS, trans. Hippocrates. Vol 1. Cambridge, Mass: Harvard University Press, 1923:71, 73.

3. Trachtman LE. Why tolerate the statistical victim? Hastings Cent Rep 1985;15(1):14. 4. Blaney R. Why prevent disease? In: Doxiadis S, editor. Ethical dilemmas in health pnmotion. New York, NY: John Wiley, 1987:53. 5. MillJS. On libery. Indianapolis, Ind: Bobbs-Merrill, 1956:13. 6. Leff AA. Unspeakable ethics, unnatural law. Duke LawJ7 1979;1979:1229-49. 7. Thalberg I. Socialization and autonomous behavior. Tulane Stud Philos 1979;28:21-37. 8. Doxiadis S. Conclusions. In: Doxiadis S, editor. Ethical dilemmas in health pmmotion. New York, NY: John Wiley, 1987:225-9. 9. Hannon BM, Lohman TG. The energy cost of overweight in the United States. Am 7 Public Health 1978;68:765-7. 10. Beauchamp DE. Public health and individual liberty. Ann Rev Public Health 1980; 1: 124. 11. Jackson R. Issues in preventive health care. Ottawa, Ont: Science Council of Canada, 1985. 12. Guttmacher S, Teitelman M, Chapin G, Garbowski G, Schnall P. Ethics and preventive medicine: the case of borderline hypertension. Hastings Cent Rep 198 1;1 1 (1): 1 2-20. 13. Eisenberg L. Value conflicts in social policies for promoting health. In: Doxiadis S, editor. Ethical dilemmas in health pnmotion. New York, NY: John Wiley, 1987:99-116. 14. Rae-Grant N, Thomas BH, Offord DR, Boyle MH. Risk, protective factors, and the prevalence of behavioral and emotional disorders in children and adolescents. 7 Am Acad Child Adolesc Psychiatry 1989;28:262-8. 15. MarfinJ. Organization of ethical control. In: Doxiadis S, editor. Ethical dilemmas in health promotion. New York, NY: John Wley, 1987:195-212. 16. Macdonald LA, Sackett DL, Haynes RB, Taylor DW. Labelling in hypertension: a review of the behavioural and psychological consequences. 7 Chron Dis 1984;37:933-42. 17. Milne BJ, Logan AG, Flanagan PT. Alterations in health perception and life-style in treated hypertensives. 7 Chron Dis 1985;38:37-45. 18. Goodman LE, Goodman MJ. Prevention --- how misuse of a concept undercuts its worth. Hastings Cent Rep 1986;16(2):26-38. 19. Arieff I. Networks urged to promote good nutrition. The Globe and Mail 1991 June 4:D2. 20. Fletcher D. Hospitals pay price of crime and violence. Daily Telegraph 1991 May 8:7. 21. Dupuis HM. Ethical aspects of reproductive medicine. In: Doxiadis S, editor. Ethical dilemmas in health promotion. New York, NY: John Wlley, 1987:153. 22. Payer L. Medicine & Culture. New York, NY: Henry Holt, 1988. 23. Manciaux M, Sand EA. Promotion of child health. In: Doxiadis S, editor. Ethical dilemmas in health promotion. New York, NY: John Wley, 1987:165. 24. Bulger RJ. Covenant, leadership, and value formation in academic health centers. In: Bulger RE, Reiser SJ, editors. Integrqv in

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