There are various reasons why efforts to promote “support for self-management” have rarely delivered the kinds of sustainable improvements in healthcare experiences, health and wellbeing that policy leaders internationally have hoped for. This paper explains how the basis of failure is in some respects built into the ideas that underpin many of these efforts. When support for self-management is narrowly oriented towards educating and motivating patients to adopt the behaviours recommended for disease control, it implicitly reflects and perpetuates limited and (...) somewhat instrumental views of patients. It tends to: restrict the pursuit of respectful and enabling ‘partnership working’; run the risk of undermining patients’ self-evaluative attitudes ; limit recognition of the supportive value of clinician-patient relationships; and obscure the practical and ethical tensions that clinicians face in the delivery of support for self-management. We suggest that a focus on enabling people to live well with their long-term conditions is a promising starting point for a more adequate conception of support for self-management. We then outline the theoretical advantages that a capabilities approach to thinking about living well can bring to the development of an account of support for self-management, explaining, for example, how it can accommodate the range of what matters to people for living well, help keep the importance of disease control in perspective, recognize social influences on people’s values, behaviours and wellbeing, and illuminate more of the rich potential and practical and ethical challenges of supporting self-management in practice. (shrink)

In this paper, I summarize the medical evidence regarding the auditory and non-auditory effects of noise and analyse the ethics of noise and personal autonomy in the social environment using a variety of case studies. Key to this discussion is the fact that, contrary to the traditional definition of noise, sound can be noise without being annoying, as the evidence shows that some sounds can harm without being perceived. Ultimately, I develop a theory of ‘noisy autonomy’ with which to guide (...) us in discussing the public health ethics of noise and other sounds. (shrink)

Recent articles published in this journal have highlighted the shortcomings of individualistic approaches to health promotion, and the potential contributions of relational analyses of autonomy to public health ethics. I argue that the latter helps to elucidate the former, by showing that an inadequate analysis of autonomy leads to misassignment of both forward-looking and backward-looking responsibility for health outcomes. Health promotion programmes predicated on such inadequate analyses are then ineffective, because they assign responsibility to agents whose social environment inhibits their (...) ability to act on such responsibilities; inequitable, because the social barriers to autonomous agency display a socio-economic gradient; and stigmatizing, because they license blaming of individuals for their own poor health without taking into account how reasonable it is to hold these individuals responsible, given the social barriers to autonomy they face. I further sketch how incorporating a relational understanding of autonomy could help to produce health promotion programmes that do not succumb to these difficulties, while avoiding coercive paternalism, exploring potential applications in ecological approaches to health promotion. (shrink)

Life with chronic disease and chronic care is hard and people who live in disadvantage may lack the freedom to prioritise their care because of increased c.

Health-promoting nudges have been put into practice by different agents, in different contexts and with different aims. This article formulates a set of criteria that enables a thorough ethical evaluation of such nudges. As such, it bridges the gap between the abstract, theoretical debates among academics and the actual behavioral interventions being implemented in practice. The criteria are derived from arguments against nudges, which allegedly disrespect nudgees, as these would impose values on nudgees and/or violate their rationality and autonomy. Instead (...) of interpreting these objections as knock-down arguments, I take them as expressing legitimate worries that can often be addressed. I analyze six prototypical nudge cases, such as Google’s rearrangement of fridges and the use of defaults in organ donation registration. I show how the ethical criteria listed are satisfied by most—but not all—nudges in most—but not all—circumstances. (shrink)

There have been calls for some time for a new approach to public health in the United Kingdom and beyond. This is consequent on the recognition and acceptance that health problems often have a complex and multi-faceted aetiology. At the same time, policies which utilise insights from research in behavioural economics and psychology have gained prominence on the political agenda. The relationship between the social determinants of health and behavioural science in health policy has not hitherto been explored. Given the (...) on-going presence of strategies based on findings from behavioural science in policy-making on the political agenda, an examination of this is warranted. This paper begins by looking at the place of the SDoH within public health, before outlining, in brief, the recent drive towards utilising behavioural science to formulate law and public policy. We then examine the relationship between this and the SDoH. We argue that behavioural public health policy is, to a certain extent, blind to the social and other determinants of health. In section three, we examine ways in which such policies may perpetuate and/or exacerbate health inequities and social injustices. We argue that problems in this respect may be compounded by assumptions and practices which are built into some behavioural science methodologies. We also argue that incremental individual gains may not be enough. As such, population-level measures are sometimes necessary. In section four we defend this contention, arguing that an equitable and justifiable public health requires such measures. (shrink)

Individuals are at risk of acquiring untreatable agents of infection when they travel to countries where antibiotic-resistant agents of infection are prevalent, and particularly when they travel for healthcare. Uncertainty with respect to the overall political and economic consequences seems to underlie the reluctance of public health authorities to issue relevant travel advisories. The conditions of choice, the act of choice and the consequences of choice can each be a primary focus of ethical appraisal of public health policy. The ‘value (...) of choice’ account provided by Scanlon draws attention to the value of the choices that individuals are given, and the potential for reasonable rejection of policies that do not give adequate emphasis to the conditions of individual choice. There is both instrumental and symbolic value in informing people of the risk of acquisition of antibiotic-resistant microbes associated with health tourism. We cannot reasonably reject a principle of actively informing unless there are insurmountable countervailing reasons. These reasons should be explicit and subject to review. If health tourism is a concern then we might also consider how best to facilitate alternative choices. (shrink)

This article analyses the paternalistic justification of the world’s first mandatory tobacco plain packaging policy, which came into force in Australia in 2012. The policy is setting international precedence, with a range of developed and developing countries planning and implementing similar policies. Understanding the paternalistic dimension of the policy is therefore of imminent international importance. The policy meets important ethical benchmarks such as respect for citizens’ self-interests and protection of others against harm. However, plain packaging faces a number of ethical (...) challenges: the policy is a controversial type of paternalism; it runs partially against the harm principle; and it fails to meet key operational criteria. (shrink)

This article considers the ethical dimensions of attempts to ‘personalise’ health and social care services in the UK. Personalisation is identified as closely related to efforts to introduce elements of neoliberal marketisation into public service provision, particularly through the introduction of consumer choice for services users. We consider two areas of ethical concern surrounding personalisation: its contribution to social justice agendas and the enhancement of service users’ autonomy. While personalisation in general, and consumer choice in particular, has been presented as (...) positively contributing to both social justice and autonomy, we critically revaluate these claims. We draw on the work of Nancy Fraser and relational theories of autonomy to highlight the ethical complexities of personalisation and the potentially negative effects that the extension of consumer choice may have on promoting social justice and supporting substantive forms of autonomy. We suggest that understanding and negotiating these complexities imposes ethical constraints on the ways in which, and extent to which, health and social care services can be defensibly personalised. (shrink)