The Politics of Public Health and Public Health Law

by David Townend (Associate Professor of the Law of Public Health and Care, HES)

Many of the members of HES are engaged in the metamedica of public health. However, what is the future for public health when our understanding of genetics makes medicine and pharmacy an increasingly tailored, individual-centred activity? Once we know that a particular drug therapy is only effective for particular individuals, and we are all different, is that the end of 'public health' as we know it?

I am not sure about this. Whenever someone says 'we are all individuals', I recall the lines from the Monty Python film The Life of Brian. Brian gives an impassioned speech to the crowd gathered outside his window.

Brian: "You're all individuals."

Crowd: "Yes, we're all individuals."

Brian: "You're all different."

Crowd: "Yes, we are all different."

One Man: "I'm not."

To me, that is something of the nature of Public Health. It has always been about individuals together. The influenza epidemic in 1918 can be seen as a single event, but equally it is a series of individuals all being affected by influenza. It is at the same time an individual experience and a collective issue. And the same is true of the modern threats, of obesity or cancer, and of failures in the supply of water or of starvation. Health is both an individual and a collective experience.

To define something as 'public health' is not, at its heart, a medical action. It is a political action. To say that influenza, or obesity or cancer, or clean water or food supply is a matter of public health is to change it from an individual problem to a political problem. Further, to move from the individual to the public, political claim is also to require a solution. It is a statement about equality and equity. Together we acknowledge this problem and the need for a collective solution.

And so in the new public health chapter that opens with greater understandings about the individuality of medical and health problems, the political activity that is 'public health' remains at the fore. It remains the pursuit of ensuring that health and well-being are provided for all regardless of their genetic predispositions. It is a matter of ensuring that there is no discrimination through the observation of genetic difference. It is about ensuring that drug and other therapies continue to be pursued for all. We do not stop seeing obesity or cancer as a public health issue because we know that it is highly individual in its character, because in great part the public health aspect of these diseases and conditions is the access to healthcare and the development of responses to the problems.

If anything, as we understand the individuality of disease, the need to maintain a 'public health' is paramount, because an appeal to the 'public health' is an appeal in the public interest. The public interest concerns, at its heart, the recognition that individually we are concerned, quite naturally, with our own individual interests and, instinctively, at best with the interests of our families and those who are our immediate neighbours. The public interest ensures that we are forced to look beyond our immediate, personal world to see our connectedness with other people. This is not simply an enforced altruism. It is in our own best interests that we treat the interests of others as equally important as our own interests. If we do not, then what claim do we have on other's resources when we are in need?

And this is where the Law of Public Health takes a form and shape. Law, and the Rule of Law, is also the vehicle of the public interest. Its claims to fairness and justice are not merely rhetorical claims. Courts, lawyers and the machinery of Law do not have to subjugate themselves to the interests of the powerful. Law creates its own narrative, its justificatory story-line about how justice appeals in each claim to its justificatory authority. Indeed, Law is the only response to the almost inevitable exasperation in modern democratic society when confronted by the sight of injustice and inequality, of unfairness and the victory of greed and oppression - 'what can we do about it?' What we can do is reclaim the Rule of Law.

The Rule of Law - the active pursuit of the fairness and justice claims of Law, worked out, in particular through robust, impartial and rigorously observed procedural Law - is centrally important to Public Health. The Rule of Law ensures that the political activity of Public Health, locally, nationally and internationally, finds fair and just translation into policy and action. It is the only real mechanism that enables individuals to call the political and economic classes to account.

Of course, I am not claiming that Courts and Lawyers are not themselves part of that political and economic class. Clearly they are. Often, procedural, substantive, and remedial Law is manipulated to ensure that the interests of the political and economic classes are not only protected and furthered, but are given a veneer of normative respectability through the blessing of the Law. But at the same time, because Law needs to use a language of fairness and justice in order to create the veneer, it leaves itself open to account in its definition of 'fair' and 'just'. That is the opportunity for the political activity of Law. That is the moment when the inequalities that require us to recognise a need for 'public health' can be raised; when the shout for fairness and justice can be heard above the clamour for self interest.

When Sir Joseph Bazalgette engineered the sewerage system in London, or Dr John Snow saw the waterborne nature of cholera, they were engaged in the political activity of public health. When we vaccinate or engage in health promotion campaigns, when we research and identify a new threat to people's health and well-being, we are engaged in political activities. Public Health Law is equally political. It is about ensuring that individuals, regardless of their economic voice, enjoy the universal aspiration to health and well-being. It is the vehicle for ensuring that we all can equally respond "yes, we're all individuals."

From the Educational Trenches: It's all about Habit Formation

By Rob Houtepen (HES)

Rob is responsible for the program in clinical ethics and health law in year 3, 4 and 5 of the Maastricht Medical School (r.houtepen@mastrichtuniversity.nl).

The discourse about teaching and end terms is usually framed in terms of knowledge, competencies, behavior and attitude. Thus, medical ethics teaching is supposed to account for itself in those terms: aiming always for comprehensible rationality, preferably for practical utility and arguably for sufficient empathy. But the universal experience from ethics teaching in medical schools is that:

1. Except in dramatic cases, it’s hard to attract and keep attention from these very intelligent and motivated, but practically minded and not too reflective students.
2. Ethics is perceived by the students at most as a worthwhile addition to the core of medicine, rather than part of such core
3. It’s realistic to be skeptical about the manner and degree to which ethics will function in practice as the desired (self) reflective critical component of a practice that is dominated by stimuli to achieve a high turnover of sufficiently satisfied patients. These stimuli are both administered by the system as a whole and by the current doctors working in it.

Reading the excellent study by Yolanda Witman (2008) on medical leadership convinced me that those problems can only be addressed sufficiently by introducing the concept of the ‘medical habitus’. It reminded me that the so called ‘hidden curriculum’ in medical education is as powerful today as it has always been. The standard initial student motivation is ‘helping people by solving their medical problems’. As long as they do not feel themselves sufficiently competent in medical problem solving, they are not really open to any messages that might detract them from this pursuit. In fact, anything outside the paradigmatic patient coming to the doctor for a ‘real’ (i.e. clearly somatic) medical problem (“What can I do for you now within the limits of my possibilities?”) usually fails to draw their attention anyhow: so much for prevention, care and social aspects. And a person with authority, to them, is either a doctor or someone who clearly promises to make them a better doctor, i.e. medical problem solver.

Witman researched how peer group pressure works among doctors in hospital medicine. She derived her core concept of ‘habitus’ from the French sociologist Pierre Bourdieu: the mental structure that individuals develop within a certain structured social environment, the way they are inclined to perceive and value the world and to act accordingly. A habitus develops in interaction between the personal and the social, within the social space of a specific practice. This social ‘field’ is also contested in a way that leaves room for variation and change. The medical habitusis an ensemble of enduring, largely unconscious schemes of perception and evaluation that stimulate and direct a doctor’s action. It contains values and inclinations which are rooted so deeply that they no longer require conscious processes or rational choices at the everyday level. This habitus is, to an important extent, literally embodied: it is molded into a specific pattern of action, movement, demeanor etcetera. It is the typical doctor’s radiation of rationality, goal orientation, self assurance and openness. This is developed from role models and among the peer group, typically ‘between the lines’.

The concept of habitus is foundational and overarching in relation to cognition, competence, behavior and attitude. It denotes the interplay and pattern of these elements and how they are secured into a self evident basic attitude. For doctors this should include an academic attitude, a patient directed attitude and an attitude of accountability. You do not develop such an attitude on your own and in an empty space, but as a functional adaptation to a specific role in a specific practice.

I have come to the conclusion that ethics education (as well as education in academic thinking, but that’s another chapter) should be directed at influencing the developing habitus of medical students. And I’m convinced that this will not work on a diet of ‘applied ethics’. It’s all about habit formation, a habitus encompassing the values that ethics would like to see firmly established in doctor’s actions: mutual trust, patient directedness and accountability. There’s more to that.

From The Educational Trenches A personal statement as to why and what

By Rob Houtepen (HES)

Rob responsible for the program in clinical ethics and health law in year 3, 4 and 5 of the Maastricht Medical School (r.houtepen@mastrichtuniversity.nl).

‘Practice what your preach’ were the first words of my first contribution to this website. Well, that’s all nice for others, but I prefer preaching about my own practice. After more than 10 very intensive years as an initial outsider in medical education, I feel a need to collect my thoughts in public. I’m afraid it will already take several articles to clarify what I’m on about. I intend to publish those in Dutch, but I hope writing a regular blog will help to organize my thoughts.

The subject of this blog is teaching ethical reflection in a problem based learning group, since my experience mainly derives from that practice. It’s not really intended to be self advertisement. In fact, it coincides with the results of an analysis of the evaluation forms of a number of those groups. These showed that, on average, I got slightly lower scores than my colleagues in the program that I’m responsible for. A bit puzzling and worrying, but then again, I’m the norm (if only because of the large number of groups that I do and my responsibility for the format) and I sincerely congratulate all my colleagues in performing above the norm. So I’m just the most experienced, not necessarily the best. And I can assure you that the program I’m responsible for will never attain a high score in student evaluations. So I guess I’m the weakest link trying to think through this weakness.

It’s all meant to be serious stuff, though, and the first installment is one hundred percent academic and dry. But from then on a peculiar penchant for heavy handed irony and low comedy ought to enlighten my texts. The program is outlined below, but I can definitely promise that it will not be followed in that particular order or even with those particular subjects and titles. It just gives you a clue what I’m on about. An excellent way to prevent me from putting all of this into practice is to react to the content: I’d like to be on a collaborative adventure here.

I: It’s about habit formation

II: Ethical theory and educational practice

III: In between different professions

IV: Practice, norms, rules and values

V: The core values of medicine

VI: The three goals of academic thinking education

VII: The habit of critical thinking

VIII: SMILEE, an educational philosophy

IX: GRGE (HE&HL): reflections on a format

X: Diversity and the elusive patient

XI: Slow Ethics

XII: The role of the ethics teacher in a problem based discussion group

XIII: What should assessment in an ethics program look like?

XIV: Medicine as a practice: what should that mean?

XV: Learning from discussion and deliberation

XVI: The legal model as a paradigm for the medical model of decision making

XVII: On the importance of reading reflective books

XVIII: Having a laugh with student evaluations in numbers