RESEARCH AND METHODOLOGIES
Personalismo per l'etica della sanità pubblica
Carlo PetriniI; Sabina GainottiII; Pablo RequenaIII
IUnità di Bioetica, Presidenza
IICentro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Rome, Italy
IIIPontificia Università della Santa Croce, Rome, Italy
In public health ethics, as in bioethics, utilitarian approaches usually prevail, followed by Kantian and communitarian foundations. If one considers the nature and core functions of public health, which are focused on a population perspective, utilitarianism seems still more applicable to public health ethics. Nevertheless, faulting additional protections towards the human person, utilitarianism doesn't offer appropriate solutions when conflicts among values do arise. Further criteria must be applied to protect the fundamental principles of respect for human life. Personalism offers similar advantages to utilitarianism but warrants more protection to the human person. We suggest a possible adaptation of personalism in the specific field of public health by means of four principles: absolute respect for life or principle of inviolability; subsidiarity and the "minimum" mandatory principle; solidarity; justice and non discrimination.
Key words: personalism, public health ethics, principles.
Nell'etica della sanità pubblica, come in bioetica, spesso prevale un approccio utilitarista, seguito dall'etica kantiana e comunitarista. Se si considerano la natura e le funzioni chiave della sanità pubblica, incentrate su una prospettiva collettivista o di popolazione, l'utilitarismo sembra maggiormente applicabile all'etica della sanità pubblica. Eppure, in caso di conflitto tra valori, l'utilitarismo spesso non offre soluzioni appropriate, poiché non fornisce protezioni aggiuntive alla persona umana. Dunque, per proteggere i principi fondamentali del rispetto per la vita umana, si devono applicare ulteriori criteri. Nell'analisi dei problemi etici nella sanità pubblica il personalismo offre vantaggi simili all'utilitarismo, garantendo maggiore protezione alla persona umana. In questo lavoro si propone un adattamento del personalismo all'ambito specifico della sanità pubblica con l'adozione di quattro principi: rispetto assoluto della vita o principio di inviolabilità; sussidiarietà e principio del "minimo" obbligatorio; solidarietà; giustizia e non discriminazione.
Parole chiave: personalismo, etica della sanità pubblica, principi.
INTRODUCTION: THE MORAL MANDATE OF PUBLIC HEALTH
Public health ethics is a relatively young discipline. Ever since the word "bioethics" was coined, the subject has been focused on individual aspects, like the doctor-patient relationship, clinical experimentation, human life, birth, death. Public health ethics has received little attention compared to the efforts spent on clinical ethics [1, 2]. This lack of attention to public health ethics also depends on the difficulties of precisely defining public health, its domain and its core functions. Several definitions of "public health" have been proposed. Some are narrow and focused primarily on communicable disease control. Some are wider and consider the role of social structures (e.g.: discrimination, homelessness, socioeconomic status) in health promotion. A general definition considers public health "The society's obligation to assure conditions for people's health". Its functions are the assessment of community health needs; the development of policies, informed by scientific knowledge; and the assurance of services that are needed for the community's health . In this perspective the missions of public health are the promotion of physical and mental health, and the prevention of diseases, injuries, disabilities [3, 4]. The main focus in public health is on prevention rather than treatment, on populations rather than individuals, on collective goods rather than personal rights.
In 1985 Geoffrey Rose proposed that targeting preventive interventions at "high risk" individuals would have minimal effects on the population's health. Instead, he argued, reducing all the risk by reducing a small amount of risks in the entire population, irrespective of the baseline risks, would maximize the benefit of preventive interventions. This situation has been defined as the "prevention paradox"  and the "population approach" which results form Rose's reasoning has been defined as one of the "absolute truths" of preventive medicine . The problem with public health is that preventive interventions apply to the entire population, but its results are weakened at the individual level. Individual wellbeing however should not be seen as opposed to collective wellbeing. Instead, public health involves a person's obligation to care also for the wellbeing of other persons, gathered in communities. The mandate to assure and protect public health is inherently a moral one.
BIOETHICS AND PUBLIC HEALTH ETHICS
The delay in the bioethical investigation on public health and the apparent conflict between individual and public interests has led several authors to highlight the differences between classical bioethics and public health ethics, the latter focusing on collective aspects, such as the sharing of risks and benefits, the definition of socially acceptable levels of risk and the acceptability of compulsory interventions (screening, testing, vaccination, etc.) . According to these authors the biomedical model (which is usually tightly regulated and based on the informed consent of individual subjects) doesn't apply to public health . Other authors consider this conflict baseless. They observe that physicians have critical public health obligations  and that an oversimplified view of public health ethics may give rise to unfounded conflicts . To synthesize, ethical problems in public health are identified when individual rights and public interests come into conflict .
Ethical issues raised by this conflict in public health include:
- the government's role in coercing or influencing health-related behaviour;
- the use of incentives (economic or otherwise) to promote health;
- the balance between public interventions and individual autonomy;
- the definition of a socially acceptable level of risk;
- the fair distribution of risks and benefits among the population;
- the need to provide definitive answers or recommendations on the basis of uncertain data;
- compulsory interventions (screening, testing, vaccination, etc.) administered in a way that does not follow the requirements of informed consent;
- equitable access to health care;
- reduction in health status disparities.
Codes, guidelines and the quest of a foundation
Codes and guidelines for public health ethics have been proposed by professional organizations.
The most known is probably the Principles of the Ethical Practice of Public Health code by the American Public Health Leadership Society, which lists key principles for the ethical practice of public health. The accompanying statement of the Code lists key values and beliefs, upon which ethical principles are based . Other papers draw up lists of operational criteria that must be fulfilled (although they are not sufficient) to meet the fundamental ethical requirements of public health practice [13-15]. Nevertheless, in public health ethics also the reasons founding these statements and operational criteria must be analyzed. Statements and criteria enunciated in codes, documents and journal articles are often defined as "principles" but the term might dim the quest of a foundation. The word "principle" indeed easily recalls the classical principles of bioethics (autonomy, beneficence, nonmaleficience and justice), whose application doesn't solve all the problems arising in bioethics and public health ethics. In order to perform a foundational discourse, in fact, it is not sufficient to elaborate conceptual paradigms that are adequate for the solutions of extreme cases and based on a pragmatic and flexible consensus, according to the circumstances and without any hierarchy among principles. The quest for a bioethical foundation is complicated by the existence of a pluralistic set of criteria which remain extremely difficult to reconcile. Nevertheless, the coexistence of several systems of reference, shall not be a pretext to avoid bioethical research. It would seem reductive, in fact, that before the plurality of ethical models of reference only formal rules could be established, simply based on the principle of tolerance for each of the individual ethics, which is in turn a form of indifference towards the very existence of ethical values, above all if one reflects on the human and social relevance of bioethical problems . This paper does not provide a complete analysis of all ethical attitudes in public health. Its aim is rather to synthesize a perspective which, in our opinion, gives a foundation to public health ethics. This foundation, we believe, offers a morally acceptable balance between personal and common values, rights and duties.
The quest for a foundation can move from the assumption that bioethics and public health ethics do in fact converge. As observed by Jonathan M. Mann, for example, care and respect for personal rights are also critical in the achievement of community's health, besides individual health . In this view caring for the single person is the best way to achieve the individual as well as the universal good. The concept can be applied in public health like in clinical practice. In a recent work Lo and Katz analyze some ethical questions which do arise in public health emergencies, when decisions are based on a doctor's clinical judgment.
They conclude that in public health emergencies physicians can still pursue the patient's good, even acting within the limits set out by public health authorities. The authors carry out a procedural analysis of the emergency situations but do not question -as this is not their primary focus-the ethical theory that would better help one solve the issues at stake . In this paper we present an ethical model, personalism, which is commonly used in clinical bioethics and which may be applied to public health ethics.
Theories of public health ethics and their relation with personalism
Usually the supposed conflicts among individual rights and the collective health is analyzed through several ethical systems. They include utilitarianism, Kantian ethics (or deontologism) and the so called communitarian ethics . Also, mention is often made of virtue ethics, which derives from a renewal of Aristotelian ethics . As yet, few scholars have made reference to personalism in public health ethics. This article follows a first concise proposal of adopting personalism as ethical model in public health decision-making . Apparently, personalism's person-centered proposal seems opposed to public health's primarily collective concerns. This perspective however seems to us a privileged point to draw the right limits to a possible "intrusion" in the persons' lives and freedom for public health grounds. Personalism aims at solving collective problems without neglecting individual instances. Undeniably, some elements of personalism are common to the above cited models. Personalism however is inassimilable to other theories. For example, the utilitarian approach typically considers the cost-benefit assessment as a main criterion in decision-making. Differently, personalism considers the risk-benefit assessment more adequate than the cost-benefit assessment both because burdens are not only economic and because (economic) "costs" and (non economic) "benefits" are not homologous values. Moreover, personalism takes into account not only "risks" and "benefits", but also other values. Indeed, according to personalism, deontological considerations must precede and integrate the balancing of possible consequences of public health interventions. Being centred on the person, personalism prevents interventions which are valuable at the collective level but may prove detrimental at the individual level. Like communitarian ethics, personalism emphasizes collaboration rather than conflict, which is upmost in current clinical bioethics, and is a constitutive and quasi foundational element of utilitarianism and of the different deontologisms. In our view overemphasizing conflict negatively influences decision making. This doesn't mean that personalism allows to overcome all conflicts. Rather, personalism is focused on conflict's prevention. This is made possible by the anthropological foundation of this proposal. We believe that contemporary public health ethics (like bioethics) needs a more deepened anthropological reflection, which is a central issue of personalism, in order to overcome conflicts which arise in public health, but mostly as a valuable instrument to prevent them. If the "preventative" paradigm is deemed superior to a paradigm based on "conflicts resolution" in clinical bioethics, this is still more true in public health.
PERSONALISM AS AN ETHICAL PROPOSAL FOR BIOETHICS
Personalism has had several formulations in the philosophy of XX century , some of which are more suited for bioethics. Among these, ontologically based personalism theorized by Sgreccia can be applied to public health ethics .
The core and foundational principle of ontologically based personalism, can be so expressed: "The right approach towards the living person per se consists in unconditionally recognizing his being and dignity (...), in loving the inviolability of human life and protecting all of its exteriorizations, in primis, on the side of human rights" . But this general principle doesn't tell yet how to value the different options which are available for decision making in public health. This principle requires specification, just like the four canonical principles (autonomy, beneficence, nonmaleficience and justice) must be specified in clinical bioethics [24, 25]. Here two levels of specification will be offered. First, a formulation of the general principle will be given with reference to the socio-political community. Second, principles well-suited for public health problems will be listed. When applied to public health ethics, personalism stresses the importance of respect for freedom and tolerance, which are among its core values . Theorized this way the principle may still seem contrary to public health concerns, which are focused on collective welfare. However, we consider that the best strategy in public health is to leave wider space to individual actions and to warrant the community's health with a minimal loss of individual freedom. When we mention respect for freedom we do not refer to the classical "autonomy principle"of bioethics, for which actions are valuable if they derive from a person's autonomous (not externally influenced) choice. Respect for freedom is a wider concept than autonomy. As suggested by Wolder and Fleischman, the idea of individual autonomy, that is a firm point in clinical bioethics, should be widened in public health . Personalism does this by a rational evaluation of the content of personal decisions. Most liberal and libertarian philosophers "define freedom in negative terms: their liberalism amounts simply to a condemnation of force, coercion and interference in human life (...). The deepest commitment of liberal political philosophy is to individualism" . Therefore, liberals articulate liberty as "radical autonomy", that is "the freedom both to make one's own choices and to define for oneself one's own conception of the good" . On the contrary, "ordered autonomy" suggested by personalism is "the freedom to use one's power of self-determination in a responsible manner in accord with the objective moral order" .
SPECIFYING THE PERSONALIST PRINCIPLE FOR PUBLIC HEALTH
Principles of tolerance and respect for freedom are not sufficient to analyze all public health circumstances like disease prevention, sanitary emergencies, the allocation of scarce resources and public health protocols and lines of research. Here we propose other principles starting from the already mentioned "Principles of the Ethical Practice of Public Health" of the American Public Health Association (APHA), published on 2002 . These principles offer normative indications of utilitarian and deontological matrix . The twelve principles fit well with the personalist theoretical scheme. Personalism however integrates them with new principles, which are partly similar and partly different from APHA's principles: some have a wider content and others provide more stringent normative indications to assure that collective good is achieved without sacrificing fundamental personal goods. Bearing in mind the context to which they apply, further specifications of the personalist principle might include:
a) principle of absolute respect for life or principle of inviolability. This is the first principle in the hierarchy. Its content is fundamentally a negative one as it points to the necessity of avoiding all actions or healthcare policies that could challenge a person's life or physical integrity. This principle parallels the second APHA's principle, which defends respect for the citizens' rights. Nonetheless, even being limited to a single dimension of these rights, the principle of inviolability is crucial as it creates conditions to preserve all the other rights. In clinical bioethics the principle of inviolability is articulated with the principle of totality (or therapeutic principle) according to which a single part of the body may rightly be sacrificed when the global health of the person is at stake (the classical example would be the amputation of a limb for gangrene). The therapeutic principle is crucial in clinical ethics. On the contrary, the principle of totality is not suitable for public health even when sacrificing the interests of single members of the community would bring strong advantages to the society. The principle of inviolability also states a clear distinction among animals and the human person. The distinction doesn't justify the indiscriminate use of animals in research. Rather, it reaffirms the Kantian assertion that the human person, for his/her inherent dignity and unavailability, cannot be ever used as a mean. Consequently, this principle allows no theoretical justification for inhuman experimentations, or other scientific experiences where persons are treated as means rather than ends;
b) principle of subsidiarity and the "minimum" mandatory. All public health measures must value the possibility of action on the part of persons and groups in society. Public health measures shouldn't be imposed by the State if they can be freely and responsibly chosen by persons. Therefore, the personalist proposal relies on public education rather than constriction or prohibition. The principle stands to avoid temptations on the part of public health authorities to impose healthy lifestyles even when they have proven to be effective. Public health authorities are surely responsible of a country's public health and in certain situations they will have to use coercive means, together with the available information, to deal with public health problems. On a personalist view however, public policies should always point on education rather than constriction. For personalism the contribution of intermediate and non governmental bodies must be valued in heath promotion activities. Smaller structures may help solving health problems that are not easily manageable at the central level. More help and/or autonomy for example could be left to professional and lay groups and organizations to try to solve the health problems that bear upon their members. The subsidiarity principle must be intended as a counterweight of the autonomy principle claiming for actors' mutual dependence. Promoting initiatives of individuals or groups is not promoting individualism or particularism. It is a way to encourage more human and less bureaucratized personal relations, which can better solve problems and do it in a personalised way;
c) principle of solidarity (or principle of education to solidarity). This principle is complementary to the subsidiarity principle. It is an extremely important principle especially in view of the tension among the community's health and the individual rights. Subsidiarity alone doesn't warrant the good functioning of healthcare policies if the persons, in their individual choices, do not consider the needs of the other members of society. In this perspective, personalism is more near to communitarianism than to individualism, as it asks persons to be responsible for themselves but also for the other persons in the community. Also here the focus is on public education rather than coercion. The case of organ donation from a dead body illustrates the concept. Some countries' legislations recognize the rule of implicit consent for donation, so that if a person don't explicitly express contrariety to the donation, his organs become immediately available after his death. This policy, which raises both ethical and legal questions may prove successful in the short run but risks to engender distrust towards the entire system of transplantation and result in negative consequences . Instead, persons should be educated and sensitized to voluntary consent to possible future donations. Studies describe the many difficulties of this option. Evidence however should not lead to abandoning this option, but should lead to a more deepened reflection on the best strategies to effectively sensitize persons. Efficacy cannot be the primary and solely criteria to assess validity and ethicity of healthcare policies. Promoting solidarity is another way to prevent conflicts, which are central in clinical bioethics. If a person is only interested in his or her own good, conflicts will promptly arise when he/she is required to renounce to a small part of his/her freedom. On the contrary, if he/she cares for the welfare of the community, he/she will be able to accept and promote sympathetic actions, possibly even against his/her own personal interest. Two important aspects of the solidarity principle must be stressed: the overcoming of individualism and the promotion of healthy lifestyles. In this view the principle is strictly related to virtue ethics , which promotes both. In fact, many health problems derive from unhealthy habits like drug use, alcohol abuse or a disorderly sexual life. The classical (Aristotelian) concept of virtue, which is highly valued in personalism, helps persons to pursue their own and collective good, with positive consequences for lifestyles and public health;
d) principle of justice and non discrimination. Public health interventions must fairly distribute risks and benefits among the persons involved. This principle has often been disregarded . The actual framework for action of multinational drug industries poses many challenges of the kind. Faulting a principle of justice, economicallydriven clinical experimentations will still be conducted in countries with a less stringent "culture of rights" than the host country of the industry, which is the main beneficiary of research.
Also, related to the principle of justice, is the need to promote equitable healthcare systems, to allow access to healthcare services for all the members of the community. As previously stated, most ethical problems in public health depend on a conflict between individual and collective interests. This conflict typically arise during pandemics, emergencies or disasters. In these conditions the practice of triage is often required, since the number of patients in need exceeds the number of available human and/ or material resources. Triage is an established process of medical sorting, used in ordinary and in extraordinary situations. In ordinary situations triage involves making decisions about the order in which patients will be treated based on the urgency of the patients' needs. In extraordinary situations triage may require making decisions that some patients will not receive treatment at all. Triage is typically supported by the utilitarian principle: decisions must benefit the greatest number of potential survivors. This approach is also shared by personalism. However, according to personalism a mere calculation of benefits is not sufficient. In addition to the principle of maximization of benefits, personalism suggests to take other values into account, and most of all solidarity and responsibility. These values do not offer single, clear-cut and generalizable responses: rather, they stimulate the professionals' responsibility to assess on a case-by-case basis .
Personalism as a theoretical model of ethics offers a good framework for public health ethics. As we have tried to demonstrate, this proposal may provide a solid basis for the foundation of some principles, like the principle of inviolability of human life or the principle of solidarity that utilitarianism cannot offer. At the same time personalism is closer to the real persons, and it is not so formal and cold like the moral indications that come from the deontological ethics. The centrality of the principle of solidarity makes this ethics very human and easier to understand for the general public. Likewise the focal point of personalism for public health is education and not constriction. This is why we suggest to foster the possibilities of this type of moral reasoning for the specific field of public health ethics.
The authors are very grateful to Paul Coppola, Paul O'Callaghan, Angel Rodríguez Luño, Kris Dierick and Gaetano Torlone who read drafts of this essay and provided useful suggestions.
Conflict of interest statement
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Received on 17 November 2009.
Accepted on 4 February 2010.