Since the Universal Declaration of Human Rights in 1948, medical ethics has incorporated a duty to protect human rights, while rights to a minimum standard of health and access to health care have been successively articulated and elaborated.
One recent elaboration of the right to health is the 2006 UN Convention on the Rights of Persons with Disabilities, which includes rights of people with long-term physical and mental ill health. The UN has a mandate to promote and clarify rights to health and rights based approaches to health. Yet the concept of right to health is not without debate, including the long-standing critique that conflation with right to health care presumes unlimited resources within nation states to provide for all individual health needs.
Public health on the other hand is concerned with population health over and above the needs and rights of individuals. Normally these concerns are not in direct conflict. We might be called for cancer screening as we get older; we are encouraged to vaccinate our children against infectious diseases; we are advised to exercise every day, eat five portions of fruit and veg and give up smoking.
These public health strategies either compel us or persuade us to act for the "greater good" of the nation: they aim to prevent poor population health, to preserve the financial resources of the welfare state and maintain productivity of the national workforce. Happily, if we take up these preventative measures, we are also likely to benefit individually from longer and better quality of life. Yet in principle, public health does not prioritise the individual.
What happens then, when our individual rights (including the right to health) directly obstruct "the greater good"?
Public health strategies have been at the forefront of pandemic responses in many countries, meaning that as citizens, we are now more acutely aware of the role of public health in our lives. For the greater good, we have been asked to relinquish some of our rights. We have been asked to give up freedom of movement, forgo our children’s right to education; many who needed cancer treatment or elective surgeries to maintain a minimum standard of health gave up their right to health too, specifically to protect those vulnerable to COVID.
Direct conflict on this scale between individual freedoms and the greater good do then occur, if infrequently. In a new article in BMJ Medical Humanities “War of Conscience: anti-vaccination and the battle for medical freedom during World War One”, I examine a similar episode in British history.
When WW1 broke out, Britain was just beginning to move on from a highly charged national debate on compulsory vaccination for smallpox. Compulsion had been vigorously opposed by the British anti-vaccination movement. The state relented, introducing a conscientious objector clause to the Vaccination Acts in 1898. A driving principle of the anti-vaccination movement at the time was "medical freedom", stemming directly from John Stuart Mill’s libertarian ideals. Mill said of health that:
“…each is the proper guardian of his own health, whether bodily, or mental and spiritual. Mankind are greater gainers by suffering each other to live as seems good to themselves, than by compelling each to live as seems good to the rest.”
The argument on compulsory vaccination seemed to have been won; yet when war broke out in 1914, a new inoculation for tuberculosis had recently become available. Military leaders were concerned about losing large numbers of troops to infectious diseases, as had happened in the Boer War.
Pressure came from military leadership and leading vaccinologists to introduce compulsory tuberculosis inoculation for all soldiers. Rhetoric ramped up on both sides. The anti-vaccinationists were accused of “unpatriotic agitation”. Speaking of the anti-vaccinationists, the Medical Director of Army Medical Services declared he would “commit greater atrocities than those which had been witnessed even in Belgium, could he ‘get at these people’”.
Yet the anti-vaccinationists felt their allegiance to the principle of individual freedom was the epitome of patriotism, particularly given the widely held idea that the Prussian enemy was very much devoted to compulsion in all matters:
“We had thought to have ‘hitched our wagon to a star’, and that the oriflamme of freedom, floating at the battlefront of the Allies was ours as well, by community of principle. Not so.”
The British government largely sat on the fence and ultimately avoided legislating for compulsion but kept quiet when implicit and covert forms of compulsion were applied in practice.
At times of national crisis, individual rights can clearly come into conflict with the greater national good, particularly in terms of public health.The debates that emerge from these crises will likely force into the discursive realm conceptual and ideological contradictions that need to be worked through. These are important conversations to have in the field of health.
Specifically, if we increasingly pursue rights-based approaches to health, how should we balance individual rights with those of the wider community? Where do our own rights end and those of our neighbours begin? Do positions on this reflect collectivism versus individualism; altruism versus egoism?
Should we vilify and caricature those with seemingly extreme positions or acknowledge and engage with the arguments? There may be no right answers and we may not always find a middle ground. Yet unless we notice the tension and acknowledge that conflictual positions may emerge from equally sound principles; if we simply drift along bemused by the disorderly narratives that flow around us, it seems likely that our governments will decide what is best.
Those decisions would be driven neither by respect for individual rights nor concern for the public good, but by what enables that government to ride out the crisis and survive another day.