Sandro Spinsanti

IS PREVENTION AN ETHICAL PROBLEM?

in Book of abstracts

Atti XII Congresso Nazionale Società Italiana per lo Studio dell'Arte-riosclerosi ― LII Giornate Mediche Triestine AMT

Trieste, 30 novembre - 3 dicembre 1998

p. 78

78

One cannot ask ethics to justify preventive medicine, nor even to support the pre-eminence it aspires to have over curative medicine. The saying "Prevention is better than cure" is ultimately a purely self-referential concept (to paraphrase Geoffrey Rose, it is better to be healthy than ill or dead. That is the beginning and end of the only real argument in favour of preventive medicine. And that is enough). In this connection, ethics proves to be useful when one compares the values it upholds with what is done in the name of health prevention and promotion. In the medical field, at least three models of ethics coexist, each characterized by a dominant value.

1. The medical ethics model, based on the principle of the "good of the patient". Here, preventive medicine proposes to provide a life free of illnesses and early deaths and to contribute positively to developing "full health". Ethics leads us to question whether preventive actions produce a benefit and who, within society, is to enjoy that benefit. But one must entertain a healthy suspicion about what is proposed to the patient "for his own good". Prevention, just as much as curative medicine, must be evidence-based; in other words, it must prove its effectiveness.

2. The bioethics model, which presupposes a "liberal revolution" in the medical profession, assesses actions by referring to the principle of independence. Good preventive medicine is that which aims to give citizens/consumers control over their own health, so-called "empowerment". A person's independence can be violated in several ways: by coercion (e.g. through interventions redolent of eugenics), invasion of privacy through preventive measures that interfere with certain lifestyles, down to educational initiatives that centre on manipulation and victim-blaming.

3. The social ethics model is guided by the value of equity and aims to introduce a fundamental equal right to health for all citizens. Preventive medicine consists in promoting a "healthy" rather than "pathogenic" society. Even preventive medicine must face the problem of sustainable resource utilization. In this day and age, health management must also operate within given limits. From now on, the ethical, economic and managerial quality of curative and preventive actions must be guaranteed simultaneously.