Public health, genomics and autonomy * Comment on Dr R.L. Zimmern's Genomics and individuals in public health practice: are we luddites or can we meet the challenge?

Abstract

We should be grateful to Dr Zimmern for drawing our attention to the several ways in which the genomic revolution could have important implications for the practice of public health. Given that human beings are not genetically identical, it is certainly conceivable that what is sound public health policy for one group might be irrelevant for another group and possibly even damaging to health for a third group. Indeed, we have become accustomed to the consideration of some such claims; for example that cannabis is especially dangerous for those who have a pre-disposition to psychosis. It is entirely possible that genetics might hold the key to why this is so, and thus enable us to segment the population into risk groups, not just for cannabis use, but for all manner of behaviours. Promise, though, is one thing and actuality another. Zimmern sets out his case in very general terms and I am unsure whether he believes that progress in genetic analysis is yet in a position to inform public health policy. He offers mammography as an example of where genetic information could be used to stratify risk populations, but the authors of the study that he cites conclude, ‘stratifying women according to genetic risk may improve the efficiency of screening programs. There are many questions to be answered and barriers to be overcome, however, before such potential could be realized’. As a political philosopher interested in public health, rather than a public health specialist, I keenly await to hear of relevant scientific breakthroughs, but at present, genomics does not seem to provide a challenge to public health practice, and so no basis for the thought that those who continue to follow standard approaches are Luddites. However, openness to the possibility of future developments is clearly prudent. Zimmern also draws our attention to the quite distinct issue of patient autonomy and individual responsibility, and thus to the overturning of older, paternalistic modes of practicing medicine. In itself this is not new. Medical ethics is essentially built on the idea of informed consent and thus the rejection of paternalism, which in turn reflects broader social trends. We may, however, ask how the ‘autonomy revolution’ has impacted upon public health. Oddly, it appears to have gone in reverse. We seem to have moved away from an ‘education plus individual choice and responsibility’ model to far less consensual public health policies. Prohibiting driving under the influence of alcohol or drugs, requiring the use of seat belts and motor-cycle helmets, banning smoking in public places and a whole host of health and safety regulations are all highly interventionist, and at least partly paternalistic. These were introduced, presumably, because consensual policies failed. In this respect medicine and public health have taken different trajectories, with medicine moving from paternalism to individual autonomy, and public health from individual autonomy to paternalism. Should we fight this trend in public health? Philosopher David Hume argued that human beings suffer from a type of irrationality, suggesting that we often find ourselves unable to resist putting short-term pleasures over long-term interests, however much we may regret this ‘infirmity’ in our natures, and however much we may try to school ourselves into more prudent behaviour. Accordingly, Hume thought, we need official compulsion through punishment to align short-term and long-term interest for individual and collective good. On Hume’s view one justification of government is to protect us from