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viewpointoutcomes such as recurrent illness, immunisationrates and hospital admissions. Further research tounravel the interactions between cost, socioeconomicdeprivation, and access to primary care inthis age group is needed, but developing a morecomprehensive approach to primary care fundingshould not wait.Appropriate access to primary care is pivotalto the health and well-being of New Zealand’schildren, and to their future. There are manypossible solutions to enhancing access, and theyall involve agreement and constructive debate betweenexisting primary care providers, emergencydepartments, after-hours providers, and fundingauthorities. Several funding models from healthauthorities might be possible, varying for eachcommunity, but imminent action is needed toestablish programmes that enable increased andconsistent access for children at all hours.We ask that this viewpoint article provide a focusfor debate of an issue that, while complex andchallenging, is not impossible to resolve; NewZealand children are waiting for our answer.References1. OECD. Doing better for children. Paris: OECD; 2009.2. Forrest CB, Simpson L, Clancy C. Child health services research:challenges and opportunities. JAMA. 1997;277:1787–1793.3. Andrulis DP. Access to care is the centerpiece in the eliminationof socioeconomic disparities in health. Ann Intern Med.1998;129:412–416.4. Ministry of Health. The primary health care strategy. Wellington:Ministry of Health; 2001.5. After Hours Primary Health Care Working Party. Towardsaccessible, effective and resilient after hours primary healthcare services: report of the After Hours Primary Health CareWorking Party. Wellington: Ministry of Health; 2005.6. Hodgson P. More support for free doc visits for under-6s. [Internet]Wellington: Beehive 2007 Aug 27 [cited 26 May 2010]Available from: http://www.beehive.govt.nz/node/304317. Ministry of Health. After hours service coverage and highfees: report to the Minister of Health. 18 October 2007.8. Marmot M. Fair society healthy lives: strategic review ofhealth inequalities in England post-2010. London: The MarmotReview; 2010.9. Hertzman C, Siddiqi A, Hertzman A, et al. Tackling inequality:get them while they’re young. BMJ. 2010;340:346–348.10. National Health Committee. Improving health for NewZealanders by investing in primary health care. Wellington:National Health Committee; 2000.11. UNICEF. Child poverty in perspective: an overview of childwell-being in rich countries (Innocenti Report Card 7). Florence:UNICEF Innocenti Research Centre; 2007.12. Craig E, Jackson C, Han DY, NZCYES Steering Committee.Monitoring the health of New Zealand children and youngpeople: indicator handbook. Auckland: Paediatric Society ofNew Zealand, New Zealand Child and Youth EpidemiologyService; 2007.13. Turner N, Asher I. Health perspectives on child poverty. In: StJohn S, Wynd D, editors. Left behind: how social and incomeinequalities damage New Zealand children. Auckland: ChildPoverty Action Group; 2007:73–90.14. Jaine R, Baker M, Venugopal K. Epidemiology of acuterheumatic fever in New Zealand 1996–2005. J Paediatr ChildHealth. 2008;44:564–71.15. Casanova C, Starfield B. Hospitalizations of children and accessto primary care: a cross-national comparison. Int J HealthServ. 1995;25(2):283–94.16. Veugelers P, Yip A. Socioeconomic disparities in health careuse: Does universal coverage reduce inequalities in health? JEpidemiol Community Health. 2003;57(6):424–28.17. Parker JD, Schoendorf KC. Variation in hospital discharges forambulatory care-sensitive conditions among children. Pediatrics.2000;106(4):942–48.18. Jackson G, Tobias M. Potentially avoidable hospitalisationsin New Zealand 1989–98. Aust NZ J Public Health.2001;25(3):212–21.19. Public Health Advisory Committee. The best start in life:achieving effective child health and wellbeing. Wellington:Ministry of Health; 2010.20. Starfield B, Shi L, Macinko J. Contribution of primary care tohealth systems and health. Milbank Q. 2005;83(3):457–502.21. Grant C, Turner N, York D, Goodyear-Smith F, Petousis-HarrisH. Factors associated with immunisation coverage and timelinessin New Zealand. Br J Gen Pract. 2010;60:180–86.22. Dovey S, Tilyard M. Evaluation of the free child health carescheme: a report to the Health Funding Authority. Dunedin:University of Otago; 1998.23. Dovey S, Morton L, Tilyard M. What is happening to primaryhealth care access for young children: Evaluation of the freechild health care scheme. Childrenz Issues. 1999;3(2):18–22.24. Case A, Fertig A, Paxson C. The lasting impact of childhoodhealth and circumstance. J Health Econ. 2005;25(2):365–89.25. Easton B, Ballantyne S. The economic and health status ofhouseholds. Wellington School of Medicine; 2002.26. Barnett JR. Coping with the costs of primary care?: Householdand locational variations in the survival strategies of the urbanpoor. Health and Place. 2001;7:141–57.27. Perry B. Household incomes in New Zealand: trends in indicatorsof inequality and hardship 1982 to 2008. Wellington:Ministry of Social Development; 2009.28. Perry B. Non-income measures of material wellbeing and hardship:first results from the 2008 New Zealand Living StandardsSurvey, with international comparisons. Wellington: Ministryof Social Development; 2009.29. Barnett R, Barnett P. Primary health care in New Zealand:problems and policy approaches. Soc Policy J NZ.2004;21:49–66.30. Blakely T, McLeod M. Will the financial crisis get under ourskin and affect our health? Learning from the past to predictthe future. NZ Med J. 2009;122:1307.31. Johnson A. A road to recovery: a state of the nation reportfrom the Salvation Army. Manukau City: Salvation Army; 2010.32. King A. Launch new Tamaki Healthcare PHO–White Crossafter hours service. [Internet] Wellington: Beehive 2004 Dec2 [cited 26 May 2010] Available from: http://www.beehive.govt.nz/speech/launch+new+tamaki+healthcare+phowhite+cross+after+hours+service33. Manaia PHO. Whitecross—Whangarei will only charge $5to children under 6yrs after hours and weekends. [Internet]Whangarei: Manaia PHO 2009 Sept 8 [cited 26 May 2010]Available from: http://www.manaiapho.co.nz/node/236342 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE
ETHICSObesity, autonomy and the harm principleMonique Jonas PhDAutonomy and its limitsThe value of patient autonomy and the respectdue to it is by now well recognised in health care.This recognition is visible in requirements toobtain valid consent for treatment and to acceptand respect the health-regarding decisions thatpatients reach. It is visible in efforts to enablepatients to manage their own health and to makeinformation about health and disease readilyavailable. Of course, we all know that autonomywith respect to health status or outcomes ispatchy: there are many factors that affect healthwhich are, in practical terms, beyond the controlof either patients or their physicians. Perhaps thatmakes the sphere of control that does exist all themore important. Where health-affecting decisionscan be made, for the most part, (competent)patients ought to be the ones to make them.Autonomy is limited practically and it is alsolimited in a moral sense. The requirement torespect autonomy ends where harm to othersbegins: we are not obliged to enable some toact in ways which compromise the interests ofothers. This idea is encapsulated in John StuartMill’s harm principle and has gained widespreadendorsement. 1 In a standard case, the applicationof the principle is clear: I am not obligedto stand by and watch one man attack another.In such a case, intervention is justified, perhapseven obligatory, even if the attack has all thehallmarks of autonomous action. I do not wrongthe violent man by interrupting his attack, ashis rights to act autonomously do not extend toharmful activity.Applying the harm principle is not always sucha walk in the park, however. In some cases itmight not be clear whether harm has in factoccurred: it can be difficult to judge whetheran action makes someone worse off than theyotherwise would have been. Decisions aboutchild rearing can have this quality: it may beunclear whether, for instance, a custody decisionhas harmed a child, because the outcomes associatedwith alternatives are uncertain. Part of thedifficulty here is establishing what the relevantbaseline is for identifying harm. 2In other cases, an action may have harmful consequenceswithout it being clear whether these consequenceswarrant intervention, or what kind ofintervention might be appropriate. Mill specifiedthat actions that merely cause offence to others donot warrant intervention, but others may disagree,or consider that some types of offence shouldbe prevented, but not others. In some situationsquestions may arise about the severity, rather thanthe type, of harm. An appropriate response to verymild harms might be to point them out to the ‘perpetrator’,rather than to intervene to prevent them.In other cases, it might not be clear who therelevant ‘perpetrator’ actually is. In situations involvingnumerous people, all of whom contributein some way to the outcome, establishing whosecontributions are harmful is no easy feat.The ethics column explores issues around practising ethically in primary health care and aims toencourage thoughtfulness about ethical dilemmas that we may face.THIS ISSUE: Monique Jonas, ethicist with the School of Population Health at The University ofAuckland, explores ethical considerations around the debate over whether public funding of treatmentssuch as bariatric surgery for obesity essentially harms others by unfairly laying claim to shared resources.Correspondence to:Monique JonasLecturer in Ethics, HealthSystems, School ofPopulation Health, TheUniversity of Auckland,Auckland, New Zealandm.jonas@auckland.ac.nzVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 343
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