• ethics
• autonomy

Bioethical principlism places an emphasis on autonomy. In a certain analogous way, modern promotional public health emphasises the role of self care as a key element to achieve healthy states. One of the many presumed available sources of guidance in health is information provided on the internet. Both this information’s quality and the tools to measure it are considered highly inconsistent. This topic has become a matter of bioethical concern, because of the possibilities for harm (maleficence) to potential users. On the other hand, there are large contingents worldwide consisting solely of non-consumers unable to dedicate themselves to self care practices. This brief commentary considers some issues related to a global perspective towards what may be considered pertinent to a public health ethics.

The domains of health ethics have been occupied by new issues. Emerging circumstances clearly call for the field’s revalidation. One example is the discussion of a so called “global” bioethics, not focused exclusively on problems in the economically strong nations.¹ Other emerging ethical issues involve “e-health”, or the availability of health related content through electronic information networks. New specialties such as telemedicine and cybermedicine are thus appearing in the area of medical informatics. There are already specialised journals on e-health and literature on corresponding ethical issues.

Under such circumstances it becomes untenable to insist on the traditional place of the “patient”, who requires the proximity of his/her pair—the “physician”—to be defined as such. Curiously, with the increasing distance in the patient-physician relationship, the patient’s place has received new designations. In our opinion, some of these terms are appropriate, including “medical ends user”.² Other terms are clearly up for discussion because of their premises, like “e-health consumer”³ and “consumer health informatics”.⁴

The contemporary world imposes a difficult test on all those who intend to join to it, by demonstrating adherence and the economic capacity to accompany the unceasing, whimsical trends of market consumerism. Those who fail the test and cannot afford or are denied access to the necessary commodities become non-consumers or consumer failures. They are incapable of becoming “free”, autonomous individuals.⁵ Huge contingents of the world’s population live and die in such conditions.

Still, the dominant perspective in the sociopolitical and economic road to be trod by the peoples of the planet seems to be towards globalisation, pursued by monopolistic capitalism in its various facets (especially in the so called post-industrial society, where the services and knowledge production sectors now enjoy economic hegemony).

Health promotion policies place a clear emphasis on autonomy. In general, when dealing with the notion of personal autonomy, we should be clear about the individualist premises underlying the prevailing concept of “person” in the West. Such premises become manifest in self care proposals. There are currently various forms of “healthy self building” through physical activities aimed at risk avoidance (for example, cardiovascular risk), aesthetics (production of a personal appearance with standardised forms of physical beauty and bodily attractiveness), rehabilitation (for the very obese or the middle aged who seek to “feel more fit”), and performance (athletic contests, both amateur and professional).

Certain aspects pertaining to the “fitness” concept deserve special attention.⁶ Without going into the distinctions and imbrications between this concept and that of good health, let us highlight how pertinent it is that health care is also linked to the idea of feeling fit, or feeling physically well disposed.

Subjective feelings of possessing fitness by way of disciplined training are especially important. The quest for fitness imposes a state of frequent and endless training, with ever present self scrutiny and a nagging anxiety over the possibility of “getting out of shape”. Countless men and women currently attempt to keep their bodies ready/adjusted/in shape to deal with overtly hazardous events like rallies, resistance trials in wilderness areas, x-games, etc. And they also attempt to “keep in shape” for the potentially unexpected events provided by multiple possibilities from a veritable menu of adventures in contemporary life. Yet they must also obviously have the wherewithal to consume the goods and services needed to engage in such activities.

The spread of ideas involving self care and health promotion behaviour is in full swing. A rapid search on Medline will identify a deluge of articles on this issue under the various (and not always clear) terminology that goes with it. This perception was highlighted by Kulbok and associates: they referred to the reigning confusion in the self care/health promotion field. After a critical analysis of the terminology, these authors highlighted the different meanings in the ways by which specialist use ideas and concepts inherent to the area: “health promotion”, “health promotion behaviour”, “health protection behaviour”, “disease prevention behaviour”, “preventive health behaviour”, “healthy behaviour”, and “healthy life style”.⁷

New ethical issues and sociocultural repercussions have emerged in both the health care and self care fields through mediations between the electronic media, health professionals, and users, who in turn become agents of consumption. Still, what is to be done with the vast multitude of non-consumers surviving precariously on this planet? How does one deal with issues at the societal level: poverty, inequality, and nutritional and housing deficiencies and their repercussions on illness, violence, crime, and exclusion? Such problems have the same roots as our inability to establish realistic values that are pertinent to living in contemporary times.⁸

Critics of bioethics contend that it is impossible to apply the principles of freedom and autonomy from classic principlist bioethics as instruments for moral conflict mediation in societal settings with great socioeconomic inequality,⁹ where non-consumers also tend to be more vulnerable in terms of health. In this sense the agenda of a global bioethic should also include the analysis, discussion, and development of strategies to deal with social inequalities and the vulnerability of populations that are excluded as agents of consumption. This implies not allowing health related decisions to be made primarily at the private level.¹⁰

Faced with the question of whether traditional principlist bioethics is sufficient to deal not only with moral dilemmas but also with public health problems, unfortunately our answer cannot be categorically affirmative. We face the important challenge of taking lack of autonomy into consideration as a crucial aspect for building a “public health ethic”. Although it may sound like a truism, such an ethic should also include old public health issues on its agenda. It should provide the basic conditions for autonomy (and citizenship) to populations excluded from the markets and consumption through a struggle against the contemporary causes of destitution and ignorance. In particular, it should seek ways to reduce the vulnerability and deep inequalities in the distribution of means for protection, treatment, and rehabilitation of the vast multitudes within the context of the heavy side effects of socioeconomic inequities in the “globalising” economic trends dictated by economically stronger nations. The moral arguments emerging from the confrontation between the large pharmaceutical industry and representatives of economically weaker nations (whether from the public sector or civil society) that resulted in breaking patents on antiretroviral drugs to make them more accessible to people with HIV undeniably belongs to the field of public health ethics.