| Abstract |
The basic aim of the present doctoral thesis is the investigation of the principles of autonomy and paternalism as they are intrinsically implicated in the bioethical - oriented discussion on medical care, focusing on health care policies with a special emphasis on dental health policies.
The adopted research approach consists of a theoretical as well as an empirical part. The theoretical part of the research is based on reports by international organizations and on published works. The empirical part is based on non structured interviews with key- informants, with the appropriate expertise coming from the Greek dental academic and dental trade-union communities. It is also based on archival material, deriving mainly from the periodical journals of the Hellenic Dental Association for the past fifty years. Content analysis is carried out using The Journal of the Hellenic Dental Association for the 1983- 2011 period.
More specifically, in the theoretical part of the research, the following three assumptions are taken as being of preliminary status: First, it appears that, for many years, in the wider scientific field of bioethics, with regard to determining and exercising public health care policy, the central issue has been the juxtaposition between individual autonomy and paternalism of those authorities, which are responsible for the determination and application of institutional and legislative regulations concerning the protection and the promotion of the citizen’s health on a national, international and global level. Second, that in order to blunt this juxtaposition in a justificatory way, during the elaboration of guiding ethical frameworks, procedural justice arrangements, and issues of public interest in the modern deliberative/ participatory democracies have been coming up quite frequently. Third, that in the above frame, issues on dental health policies are placed at the core of a persistent and long-lasting controversy between the supporting and the opposing parties. An example of this is water fluoridation, that is to say, the addition of fluorine to the water supply network of a region for the protection and promotion of the citizen’s dental health and for the prevention of the epidemic of dental caries.
Based on the three above- mentioned assumptions, through the discussion of issues on moral and political autonomy versus paternalism in bioethics, the research question presents itself as follows: the inquiry of the fundamental interconnections of the procedural justice arrangements and of the public interest with issues that are
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essentially related to the relation between the ethics of the law and the ethics of policy in the evaluative framing of health care policies in modern deliberative/participative democracies. Furthermore, another specific research question is posed, about the particular point of view of dental health policies in the above processes of evaluative framing, using the fluoridation of water supply networks as a case study.
At first, the essay “Public Health Ethics: Mapping the Terrain” by Childress et al. and the Report “Public Health: ethical issues” by the Nuffield Council on Bioethics are comparatively discussed. The reflections on public interest in health draw from the work “The Moral Limits of the Criminal Law”: Harm to Others” by Joel Feinberg. More specifically, concerning the fluoridation of water, the texts “Paternalism: some second thoughts” by Gerald Dworkin and “Public Health: ethical issues” by the Nuffield Council on Bioethics were analysed. A discussion on the complex theoretical difficulties of the fluoridation of water is draws on the text “Public Health Ethics” by Ruth Faden and Sirine Shebaya.
The object for the empirical research was the case of water fluoridation in Greece given the fact that already since 1974 there exists a compulsory legislation on water fluoridation, without ever being applied.
The findings of the research are summarized as follows:
institutional and legislative difficulties of a structural form in regard to the application of health care policies in Greece
structural difficulties related to the institutions and the technical infrastructures for the realization of the particular measure
contradictive arguments within the juxtaposition on autonomy versus paternalism in terms of justice, procedural justice and public interest
particular difficulties encountered at the emphasis of the measure on the prevention of the dental caries disease and are related to the importance of oral health for the human life, the significance of prevention in the sector of dental care and the meaning of dental caries disease as an epidemic.
In the discussion, deriving from the theoretical and empirical research, questions of democratic governance are brought forward, in terms of the “political ideal of deliberative democracy” and the “argument from autonomy” with reference text the essay “Deliberative Democracy: A Sympathetic Comment” by Samuel Freeman. Also the “difficult regulatory issues” with regard to the politics of life and the need
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of connecting ethics and politics to institutional innovation of modern participatory governance in order to resolve them, with reference text the Summary Report by Participatory Governance and Institutional Innovation –PAGANINI Project.
Indeed, the ethical and political dimension of legislative regulations of issues concerning the citizens’ health seems to be strong, especially if it comes to epidemic diseases which often, as it is the case with dental caries, have a multifactor causality with explicit genetic factors, as it is nowadays scientifically acknowledged by the rapid biotechnological developments and the mapping of the human genome. Thus, the speed of the scientific and biotechnological developments in the life sciences, influences rapidly, and quite often unpredictably, the unique and strategic, as many argue, relation of stewardship of public health in public policy issues.
The case of water fluoridation lies in the boundaries between moral justification, political legitimization and social acceptance of precisely the above mentioned unique and strategic relationship. It also illustrates the limits of the conflict, especially without any normative terms, (as has been shown in the theoretical part of the research) between individual autonomy and the paternalism of the authorities that are responsible for the decision-making and the application of health care policies.
Thus, water fluoridation turns out to be a hard case, unable to be resolved simply by calling on procedural justice arrangements, in terms of public interest in health care policies. Indeed it is taking on particular characteristics from the complexities regarding the nature of dental care of citizens as well as from the complexities, consecutively, of protection and promotion of dental health with the responsibility of the interconnected domains of dental science, the dental profession and public health, especially in the current era of rapid reshaping and aggravation of the global economic, social and political conditions.
Subsequently, the need of a normative discussion about the interrelation of the ethics of the good, that is, of health as a good that substitutes an aspect of human well-being, and of the ethics of the right that should govern both the ethics of the democratic legislator and of the political legitimization of the process of law-making itself, appears to be imperative in the health care policies. This is because public health is connected uniquely and strategically, as it was mentioned before, with institutional and legislative regulations and practices of modern governance.
As a consequence, certain normative demands are brought forth, stemming from the political process as “imperfect procedural justice” found in John Rawls’ Theory
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of Justice and finally based on the book Law, Ethics, Bioethics. Part one: Theoretical foundation by Pavlos Sourlas, which suggests a Kantian approach of interdependence between rights in health, democratic processes and institutional guarantees. For such an interdependence Kant’s principle of autonomy offers itself as a common background also of the ethics of the good as well as the ethics of the right in the bioethical- oriented discussion of the framing of health care policies in the modern deliberative/participatory democracies. Thus, procedural justice arrangements put in terms of public interest, instead of simply being placed in order to justify and blunt the juxtaposition between autonomy and paternalism, are transformed into ways for the essential establishment of the equal moral and political value of individuals acting also collectively. Water fluoridation as a hard case, made clear by the example of Greece, shows that the health care policies and in particular dental health policies, are an exceptionally interesting research area for these reflections in bioethics to be tested and elaborated on further.
Hopefully, the research as it is formulated in the present doctoral thesis will contribute to this direction.
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