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

ethicsCritiqueIf this account of the argument against publicfunding of treatments for obesity such as bariatricsurgery is accurate, it exposes a number ofpoints that warrant further investigation.Claim 1 makes a substantive normative claimabout the general duties of citizens. It is rathera plausible claim to make, tapping into easilyaccepted ideas about fair shares, and the moralimportance of being attentive to the effect ofone’s actions upon others. The idea is that claimsto common resources that arise from genuineand unavoidable need are legitimate, and do notwrong or harm others, whilst claims that are notso based are illegitimate, and harm others byreducing available public funds without legitimatecause.One aspect of this claim that requires clarificationrelates to baselines for harm. In what senseare those in need of health care harmed by theclaims of others? The intuitive response would beto say that the claims of one, P, reduce the fundsavailable to satisfy the claims of another, Q. Ifthat means that a lower standard of care is availableto Q, perhaps Q is harmed by P.But we wouldn’t normally think that patientsharm each other by drawing on public resources.The resources are there for all who need them,and it is in the nature of communal resources thatcompromises in individual claims are sometimesrequired. The entitlement of Q is not reducedby P, since P was never entitled to more than areasonable share, given competing demands.But this does not fully diffuse Claim 1. Thepoint it advances is that there is a differencebetween legitimate claims (those which could notreasonably be minimised) and illegitimate claims(those which the patient has in some way allowedto arise). Legitimate claims do not harm others,because they do not reduce entitlements, butillegitimate claims do: they wrongfully lay claimto resources that could otherwise have been usedto satisfy truly unavoidable health needs.The idea that we ought to minimise our claimson public resources has intuitive appeal. Butif we consider the vast range of activities thatwe consider permissible, and even valuable insociety, the idea that there is an absolute dutyto minimise claims to public resources loses itslustre. Surely we are not required to refrain fromabsolutely every activity that might elevate claimsto public resources, since many of the activitiesthat we value—having children, playing contactsports, entering certain professions (the fire service;the military; and perhaps medicine)—harbourpalpable health-related risks.To rescue Claim 1 from the perils of implausibility,it is necessary to find some way to distinguishbetween worthwhile activity of the kind that isto be fostered by society and activity that doesnot justify the associated risks. Perhaps it shouldbe rephrased as follows:‘Claim 1: Competent adults have a responsibilityto minimise their claims to limited publicresources whilst pursuing worthwhile life goals.’This rephrasing exposes its inevitably judgementalnature. To argue against funding treatment forobesity on the basis of Claim 1, one has to showthat the actions and choices that lead to obesityare not compatible with the pursuit of worthwhilelife goals. That may not be as easy as itseems. The reasons that people become obese maybe much more value-laden than one might gatherfrom some commentators. Eating is a source ofenormous personal, social and cultural importand can solidify and confirm a sense of personaland group identity. 5–9 In some cases, particularrituals and routines around food may be risky.One can object to the risk, and call for it to bereduced, without claiming that becoming obeseis in contravention of a responsibility of the sortexpressed in Claim 1.Claims 2–5 take an empirical form and thus standor fall according to the evidence. But even if itcould be demonstrated that the vast majority ofadults do recognise the health risks attached toobesity, these claims might remain problematic.Obesity often has its roots in childhood and,once obesity is established, it is very difficult tobanish through conventional means like dietingand increased physical activity. 10–12 Althoughadults may well be expected to know that obesityVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 345