The requirement to respect autonomy - The Royal New Zealand ...

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