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Posts Tagged ‘John Coggon’

Methods and Discipline in an Interconnected Bioethics

In 2014, Bioethics on April 29, 2014 at 8:45 am

I’m writing this blog post in a rather august atrium in the University of Vienna (long story), but it actually relates to a talk I gave last week at Monash University’s campus in Prato. It was one of the most stimulating, fun, interesting, and generally enjoyable conferences that I’ve been to , and was the final meeting of a group led at Manchester, looking at the Human Body, its Scope, Limits, and Future (a project on which I was previously employed).

As well as four problem-led strands, considering questions such as the use of bodily materials and human enhancement, the project had a cross-cutting focus on methods in bioethics. Given some activity of mine in relation to this (most notably my co-editorship of a special issue of Health Care Analysis), I was invited to speak to this aspect of the project. I was delighted, but also a little daunted: whilst scholars such as Jon Ives, who was at the conference, and Mikey Dunn are very much ingrained in these discussions, I’ve had more of a ‘reflective’ and ‘external’ interest (hence my heavy use of scare quotes here, even by comparison to my generally high usage).

My talk took as its impetus a few themes, but a key one was found in (ahem) a slightly caricatured representation of a wonderful paper by my former colleague Iain Brassington. It’s a wonderful paper, but one whose emphases have me raise my own questions about what normative theory means within bioethics, and whether we should focus on what individual disciplines bring individually, rather than in some sort of conjoined activity.

Iain sees a great importance for philosophy in bioethics because (as do I) he sees bioethical analysis as being directive; action-guiding. His paper is available open-access, so I’d encourage readers to digest the full argument, but to reduce some of it to Iain’s own words: “philosophers are simply more likely to be good at thinking about problems of (say) justice and just policy than are non-philosophers, just as biologists are more likely to be good at thinking about problems in ecology” (p. 29).

I am not sure about this.

Part of the merit of philosophical analysis, for Iain, is that it allows abstraction from context and thus the better scrutiny of reasons. Yet I am not sure, when we think of ideas concerning obligation, that we can so easily segregate the world we are analysing into components that reflect the ‘silos’ that our disciplinary backgrounds sometimes purport to reflect. My own legal analysis is heavily influenced by works in moral and political theory. But it is also held in some sort of check by a reminder of Raymond Geuss’ pugnacious challenge to moral and political philosophy. When (as often happens in bioethics) the context of obligation is rooted in professional, legal, institutional, social, and other systems, abstraction can remove too much. And actually, despite Iain’s claim, I’m not convinced that philosophers particularly are better at the relevant kinds of conceptual and analytical methods. (It’s an interesting empirical claim, anyway.)

Without the sort of analysis that philosophers can bring, Iain sees a danger of bioethics become plain description or zealtory. And he closes his argument by suggesting that if others do bring the sort of analysis he’s speaking about, it’s probably philosophy that they’re doing after all. So philosophy keeps its pre-eminent position within bioethics.

For me, the importance of practicability in practical ethics suggests a need for much less of a focus on disciplinary prowess, and a far greater need to share ideas; to communicate between disciplines and with others (such as practitioners, folk in policy, and so on). This concept of public ethics resonates with Jonathan Wolff’s ideas, and Iain’s paper read in the light of Wolff’s work here gives, I would argue, a better idea of the role of philosophy within bioethics. The philosophical understanding is important, but no more important than that brought by other disciplines and some sort of qualified resignation to the status quo.

To be clear, my apparent bioethical ecumenicalism here is not based on a concern rooted in bland respect for different disciplines. Rather, it is based on the view that the universe, its orders, and its inhabitants are, when dragged into theory, conceptually a lot less crisp than abstracted normative analysis often allows. Disciplinary humility is as important as celebration of disciplinary advantage.

As for the upshot in regard to methods: for whatever it’s worth, my view is that there is so much that different disciplines can bring, and so many different sorts of problems to look at, that there is little good to be gained from finding the method for bioethics (not something, to be clear, that Iain was claiming to do). Rather, our focus is better placed on ways of approaching problems, and from there working towards the best engagement of collaborators. In this sense, bioethical analysis will not always require philosophers, and to be action-guiding will need normative theorists who are willing to come back from abstraction to a messy, complex, conceptually compromised world.

John Coggon

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How and why do we value scientific freedom?

In 2014, Conferences, Gratuitous self-promotion, Publications on April 7, 2014 at 12:54 pm

With teaching over, it’s good to have a bit of time for writing and going to conferences. I’ve just got back from a trip to Rome, where I attended the third meeting of the World Congress for Freedom of Scientific Research. The meeting is a key event hosted by the Luca Coscioni Association, which aims to eradicate undue bars to science and innovation. With Simona Giordano and Marco Cappato, I edited a book on Scientific Freedom following the first of these Congresses. As well as existing in hard copy, it is available here open access.

The Congress that just took place focused on the relationship between science and politics. In my own paper, I raised issues about the central place that the public interest should take in our analyses and evaluations of scientific freedom. This cuts against some of the received wisdoms amongst members of the scientific community, who are wary of the public interest (or in related literatures on the national interest). The wariness is born of concerns that the public interest will simply be given as a dogmatic, knock-down argument against good science, with no sound rationale behind it. Whilst we should be alive and responsive to such concerns, if we are to advance scientific programmes, we also need to be able to explain how these serve the public interest.

Scientific freedom is not just a ‘negative right’; a right to be left alone (and even in instances where it is, it can still impose positive claims and costs on the State and others). And really, advocates for scientific freedom are anyway asking governments not only to permit, but also to protect and indeed promote science. In doing this, we see important roles for law and regulation, providing both a shield, where defences are needed of scientific activity, and a stage, where publicity and education are needed. In my paper, I aimed to capture the reasons for this, and to explain that those in the scientific community need to understand why the public interest may at times legitimately constrain, as well as advance, science.

The event in its entirety was quite intense, with a great range of speakers and papers. Although it was built around a shared agenda, there was nevertheless a fascinating variety of perspectives. Furthermore, the span of insights afforded was astounding. Speakers included scientists and other academics, but also activists, politicians, people working in policy, journalists, and jurists. I left with a sense that many of the practical upshots of the meeting will arise as individual developments. ‘Science’ is vast and varied. But the general movement, and the added momentum that can be found when people with associated interests come together, will add to the power of such developments.

John Coggon

HEAL teaching outside the Law School

In 2014, Public Ethics, Teaching on March 17, 2014 at 8:34 am

There’s been lots going on in HEAL over the last couple of weeks, with various research papers being presented on campus, development of a HEAL consultation response regarding organ donation after brain death, and A.M. Viens jetting off to Copenhagen where he was co-organsing a conference on Public Health Ethics. Further to all this, and of course the regular path of the academic treadmill, I recently taught at the medical school to students on the MSc in Public Health Nutrition. It’s always interesting to deliver teaching outside of the familiar disciplinary frame. For this class, I was charged with introducing ideas about public health ethics, law, and governance. This means bringing a philosophical focus that places many of the students on the course outside of their academic comfort zones.

Such a foray into ‘alien’ literatures and methods means that the teaching raises distinctive challenges both for the tutor and the students. A complexity for the students in this context comes in the open nature of many of the questions asked when bringing philosophical approaches to the curriculum. In particular, this strikingly relates to questions concerning the very meanings of public health practice, and public health ethics. For example, I got very interesting and mixed answers on whether or not I, or Penny Nestel who runs the course, can be said to work in public health.

The productivity in exploring such questions doesn’t arise in reaching the ‘right’ answer. Rather, it’s about the critical self-reflection and questioning that they trigger in the students. People who study on courses such as our MSc are motivated to work in health promotion; they are committed to what Larry Gostin characterises as an article of faith in the great importance of health. My purpose in bringing a philosophical analysis to the education is not to lessen that faith, but to invite the students to scrutinise the strength and substance of its foundations.

I find the reward of this sort of teaching really comes out in the small- and whole-group discussions. A vast range of interesting ideas and questions were raised at the recent session. I’m looking forward to starting teaching the full, ten-week course on Public Health, Law, and Ethics with A.M. Viens later this year on the MSc in public health. We’ll be able there to explore philosophy and public health in a much more sustained, and deeply engaged, way.

John Coggon

This week’s joint ICJR/HEAL event – Dr John Coggon on ‘Legal Moralism and Long-Game Healthism? – the regulation of smoking’

In 2014, Meetings, Public Ethics on March 11, 2014 at 3:10 pm

This week we have a joint ICJR/HEAL event on Wednesday 12 March 2014, from 4pm in Building 54, Room 10037 (10th Floor), with John Coggon speaking on ‘Legal Moralism and Long-Game Healthism? – the regulation of smoking’.

Abstract This paper is concerned with coercive policies and regulatory strategies that aim at a prohibitionist end whilst avoiding individual legal measures that would individually provide an outright ban on an activity. It compares jurisprudential debates regarding legal moralism, which concerns the use of law as a mechanism for enforcing moral norms, with debates in public health ethics about healthism, which refers to an ideological political agenda aimed at making people behave in ways that (apparently) promote their health. It then takes as its focus the ‘end game’ agenda in tobacco policy; a strategy designed ultimately to mean that smoking will be eradicated. Against the background of ideas designed to legitimise such health policy—such as those entailed in ‘libertarian paternalism’—the paper examines whether long-game strategies avoid or are subject to concerns that apply to immediate prohibitions. In short, it explores the question: if on principled grounds we could not ban smoking overnight, (why) is it acceptable to do so over a decades-long period?

Ethics, Politics, and Georgetown Public Health Law

In 2014, Gratuitous self-promotion, Public Ethics on February 10, 2014 at 11:42 am

Last week I was delighted to visit Georgetown University. In particular, it was a great pleasure to meet up with Larry Gostin in the O’Neill Institute for National and Global Health Law. Larry’s work has been crucial in shaping contemporary understandings of public health law and ethics; my main areas of research. It was fantastic to have the opportunity to discuss with him my own teaching and research agendas, including the work that A.M. Viens and I are up to in HEAL developing specialist teaching in Public Health, Law, and Ethics for Southampton’s new MSc in Public Health.

The primary reason for my visit was to give an invited lecture to JD and LLM students studying public health law in Georgetown Law. The lecture was entitled “Political Theory in Public Health Ethics”. In part, it involved teaching some of the fundamentals (at least as I see them!) in bringing ethical analysis to public health practice and policy. However, my main aim was to challenge the students to consider not just the nature, but also the scope, of normative claims made in the name of public health. Having examined the necessary relationships between public health and law, I invited the students to think about two distinct modes of ‘doing’ public health ethics.

In relation to the first, we studied the work of scholars who are interested in theorising: we looked at ideas concerning conceptual coherence, normative and analytical rigour, and theoretical bounds (or lack of them) to claims made in public health ethics. The lecture surveyed some of the many different ethical theories that are brought to bear on public health, and scrutinised their bases and conclusions. As regards the second, we looked at ethics in public advocacy, referring to ideas such as ‘nudge’, ‘stewardship’, and the human right to health. Here we asked not just how robust these positions are in theory, but how robust we really want or need them to be in practice.

My hope with the class was that the students would address the very basics of whatever motivates their ideas about good practice in public health law and policy; to think about what makes health promotion desirable, or even an imperative (and what brakes there ought to be on health promotion). But I also hope that it left them thinking about the potentially distinguishable roles of academic and activist, and which (neither, either, or both) they would wish to assume, and on what terms.

John Coggon

Public Health Ethics, Policy, and the Long Game

In 2014, Public Ethics on January 21, 2014 at 10:41 am

I’m writing this post in a rather sparse corner of Düsseldorf Airport, waiting to head homewards after a very stimulating two-day workshop on public health ethics. Organised by Professor Thomas Schramme and Professor Stefan Huster, at the Centre for Interdisciplinary Research, the workshop had the theme “Individual Liberty and Problems of Justice in Public Health Ethics”. It formed part of a wider, on-going research agenda that is being pursued at ZiF.

Both A.M. Viens and I attended this workshop, which had paper presentations from me, Steve Edwards, Stephen Holland, Sridhar Venkatapuram, and Kalle Grill. Intellectually it was both invigorating and challenging, with about an hour’s in-depth discussion given to each paper. My own contribution, entitled “Public Health Ethics and some Problems of Incomplete Theorising,” was based on a project I’ve been developing for some time. Working from a very broad understanding of public health (and thus also of public health ethics, law, and regulation), I sought to explore two things.

First up, I explained some basic analytical matters that I see as necessarily entailed in public health ethics. These are all built around the (widely accepted) idea that it requires us to examine freedoms and obligations concerning social, political, and commercial institutions as well as persons and populations, so should be framed in terms of political philosophy. Given that situation, and a heavy focus that inevitably falls on concerns for liberty (is this a hangover from bioethics, a ‘liberal thing’, or something else…?), I propose that a good way to enter analysis is by starting with a situation where we (purport to) give absolute respect to autonomy; philosophical anarchism. By considering the reasons why we would want to live in a political system rather than a state of nature (assuming that we would!), we present our reasons for accepting government, assessing how and why interferences with liberty are legitimate or desirable, and what values other than liberty can form the basis of political obligation. These sorts of considerations, I argued, are fundamental to, and must come prior to, any claims about specific public health imperatives.

Second, and at greater length, I explored an issue that I related to debates on theory and application of libertarian paternalism, or ‘nudges’. I began this by noting how nudges are advocated for by parties who are themselves not committed in any sense to libertarianism. Against a background of scepticism about the trust this might allow libertarians (and others concerned with liberty) to place in champions of nudge, I went on to explore an issue that (in this context) I think has received insufficient attention: the ‘long game’ in health law and policy. Here we might consider policy agendas that can only be implemented through progressive strategies, such as we see in the ‘denormalisation’ strategies concerning smoking. The questions I presented for discussion mixed normative and methodological inquiry: in essence, I asked whether it is soundly possible in evaluating laws, regulations, and measures to abstract individual policies (say a ban on smoking within five metres of the entrance to a public building) from the wider policy agenda of which they logically form a part (eradication of smoking through incremental policy-developments). This matter raises interesting philosophical issues concerning (amongst other things) the place of temporality in political philosophy and the role of individual preference in conceptions of coercive regulation.

John Coggon

Criminal Law and Public Health – Working at Cross-Purposes?

In 2013, Gratuitous self-promotion, News, Public Ethics on November 18, 2013 at 8:00 am

According to recent news reports, the city of Edinburgh is getting tough on those who seek sensual pleasures outside of the confines of their own homes.  The police have asked that condoms be banned from saunas as a way of trying to prevent sexual activity on the premises, and city Councillors have been asked to stop issuing licenses for saunas and massage parlours.

Besides being a naïve and impractical way to prevent people from having sex, there has been, unsurprisingly, a strong condemnation of such a move on the grounds of its potential negative effect on public health.  The charity Scot-pep, for instance, has warned that implementing the police proposal on condoms could lead a HIV epidemic, as well as the proposal to limit establishments where sex workers can meet clients puts them at greater risk from some of the inherent hazards of plying their trade outdoors.

There has been a long history in the United Kingdom of a connection between the criminal justice system and public health.  In some cases, it has been a beneficial relationship in which everything from firearms restrictions, requirements for seat belts, motorcycle helmets and child safety seats and restrictions on intoxicating substances, provide examples where the criminal justice system has been used to mitigate or prevent behaviours that are harmful to individual and population health.  Nevertheless, not all intersections of criminal justice and public health are mutually beneficial.  What is most notable is the distinct progression that has been made from a so-called “policing model of public health”, that often focused on ideas of moral hygiene and legal moralism, which remained influential in Britain into the 19th century, towards more social models of public health that focus on health promotion, harm reduction and social justice.

The recent proposals in Edinburgh reveal a conflict that can arise when approaching a social problem through a criminal justice lens rather than one of public health.  Even with a greater focus on individual and population health that shies away from ideas of moral hygiene and legal moralism, there remain important tensions between criminal justice and public health concerns – especially in cases where it concerns sex and sexuality.  What is needed is an approach in which the criminal law – as well as other areas of law – is used as a public health tool that seeks to promote health and well-being, as opposed to being used to punish individuals’ choices we find distasteful or undesirable. 

HEAL has a strong interest in public health ethics and law.  Two of its core members (A.M. Viens and John Coggon) were editors of a volume that was published this month by Cambridge University Press entitled, Criminal Law, Philosophy and Public Health Practice.  Bringing together international experts from a variety of disciplines, including law, criminology, public health, philosophy and health policy, it explores the theoretical and practical implications of how the use of criminal law may promote or hinder public health goals.

A.M. Viens

Burke, Biggs, and Disagreements on Who Knows Best

In 2013, Death and dying on November 4, 2013 at 7:45 am

Burke, Biggs, and Disagreements on Who Knows Best

It is my great pleasure this academic year to be teaching on our third year option in health care law, albeit that the position has only become available by virtue of our losing Jonathan Montgomery to UCL. It is a privilege to teach matters that are central to my research, and the experience is all the more enjoyable as I’ve been lucky enough to do ‘team-teaching’ with my dear colleague, and former HEAL Co-Director, Hazel Biggs.

Part of the point of, and reason for, sharing a platform with Hazel is that we can each bring our own distinct—and perhaps distinctive!—approaches to, and views on, different issues in health care law and ethics. This isn’t simply a point of expanding students’ perspectives by direct exposure to differing views, but also about allowing them to see the nature of debate and disagreement between academics in the field; on some matters, agreeing with Hazel means disagreeing with me, but more fundamentally there’s every chance that disagreeing with both of us is the best way forward!

In a recent lecture, I was reminded of a point on which Hazel and I are particularly at odds, and imagine that our disagreement reflects in microcosm quite pervasive and deeply-held disagreements amongst academic health care lawyers  more generally. Potted histories of bioethics and health care law tend to reflect an eventual (or partial) triumph of concerns for patient autonomy over a dominant, paternalistic (or worse) medical hegemony. Certainly we now find strong defences of autonomy expressed in laws governing consent and mental capacity.

But one divide that remains unbridged, even at the level of principle, is that between negative rights—a patient’s ‘absolute’ right to refuse health care interventions—and positive claims—a patient’s ‘right’, not supported at law, to demand a given intervention regardless of the views of the health care team.  The most noted authority on this point, the Court of Appeal decision in Burke, is clear that ‘autonomy rights’ do not entail a right to demand treatment.

Yet the Court leaves its presentation of principle somewhat cryptic. In negative terms, we are told clearly at paragraph 31 that the duty to treat is not founded on the patient’s demand. But rather less categorically, we are told in positive terms simply that “The source of the duty lies elsewhere.” Part of the explanation for remaining quiet on this question is a strong desire on the Court’s part not to stray into general doctrine, but rather to remain focused on the question under issue (on which it does go on to express reasons). But on what should the general duty to treat be founded? For Hazel, patient autonomy is a sufficiently strong concern that health care practitioners should have no determinative say in treatment decisions; they can advise, yes, but not dictate.

For my part, I would argue that positive claims to health care do rightly include determinative roles both for patients and health care experts. This is in part due to the exceptional nature of health care; it is something special, and something in which we demand expertise, professional judgment, and evidence-based reasoning. It is right, in such circumstances, to insist on a level of deference to clinical judgment and opinion in regard to what can be demanded from the system. My reasoning is in part too based on macro-level concerns; in a system of constrained resources, brakes must be put on what treatments can be given. Amongst good reasons for not providing a health care intervention must be that it will have no or limited efficacy; again, this is a question well judged by someone with expertise. (To be clear, other factors rightly count too, and of course in some instances a small chance of a big gain will be worth taking.)

The ethical debates will rumble on, inside and outside the classroom – but I doubt that the courts will be persuaded to provide an exclusive, general competence to patients in positive decisions.

John Coggon

MMR, Patients’ Beliefs, and Legal Coercion

In 2013, Case of the week, Key Legal Concepts, Vaccination on October 21, 2013 at 7:00 am

Over the last week or so, there’s been a lot of media coverage of a case in which Theis J, sitting in the High Court, issued a declaration that two sisters aged 15 and 11 should receive the MMR vaccination. Although the courts will (rightly) tell us that any such decision concerning the MMR vaccine is applicable only to the particular case under issue, some observers may now sense a trend developing in the jurisprudence on this question.

In the particular case, various stock health care law issues arise: what should practitioners and the courts do in the face of practical disagreement between parents?; how much weight should be given to the views of ‘mature minors’?; can practical problems legitimately interfere with a principled, ‘coercive’, legal decision? (it has been reported that, despite the judgment, the vaccinations have not been given)

A further question, raised in the case, and which causes continuous tension in English health care law concerns the treatment of patients’ (and, for minors, their parents’) beliefs. It is interesting to assess this from a wide range of angles, but here let us focus on two ways that beliefs are expressed in health care decisions.

First, we may find challenges to a patient’s conclusions on a decision, brought by reference to the quality of the reasoning that led to those conclusions. Sometimes, the courts set aside patients’ expressed wishes because of patients’ apparently faulty logic. In the recent MMR case it was noted that whilst the 15 year old child objected to the vaccination on ethical grounds (she is a vegan and says she objects to the products within the vaccine being introduced to her body), she had voiced no such objection to, hypothetically, receiving treatments that also seem to offend her vegan principles, should she fall ill. This apparent inconsistency contributed to the reasons for finding her beliefs less than compelling.

Where judges decide carefully and openly (when is it otherwise?), many will argue that it is proper—especially in the case of child patients—that the courts should not uphold a patient’s ‘rights’ to harm herself, with harm judged even by the patient’s own standards; that we can legitimately, in some circumstances, protect people from their own harmful and inconsistent reasoning.

Yet a second challenge regarding beliefs, which we also find in health care law and which is much harder to resolve, is found in cases where courts essentially disregard a belief by virtue of its very content. Here, we don’t face a flaw in the patient’s process of reasoning. In theory, English health care law aims to be deferential on belief systems; legal principle tells us that generally the basis of our decisions is not for the courts or carers to question. Yet sometimes, ‘the science’, or ‘common sense’, or ‘basic reason’ seem to lead to compelling reasons to disregard a patient’s views.  In these instances, it can be much harder, on terms consistent with legal principle, to frame a judgment that sets aside the patient’s (or parent’s) decision. If such a judgment is to enjoy legitimacy, the law needs to develop coherent means of accommodating such an approach explicitly, for children and for adults.

John Coggon

BMA Medical Book Awards: Commendation for Coggon!

In 2013, Gratuitous self-promotion, Public Ethics, Publications on September 23, 2013 at 7:52 am

On Tuesday 17th September 2013 the BMA Medical Book Awards were hosted in the Great Hall of the BMA. John Coggon’s book ‘What makes health public?’ was highly commended in the Health and Social Care category.

Cover   What Makes Health Public? 
The book is a critical monograph on public health and philosophy. It also works as a foundational resource for people working in or studying public health ethics. It is presented in three parts: Part I examines core concepts in public health, explaining what is meant, respectively, by ‘health’, ‘public’ and ‘the public’, ‘public health’, ‘public health policy’, and ‘public health law and ethics’. Part II explains why public health law and ethics require understanding of political philosophy, and demonstrates how political theory applies to health ethics and policy. Part III offers a presentation and defence of the author’s preferred political morality, explaining how the theory is developed and its implications for evaluations of potential and existing public health policy. It demands a reconceptualisation of mainstream bioethics, and reframes ethical analysis so that it can apply to contemporary problems in health policy and practice. Its objectives are both theoretical and practical. Public health ethics is a relatively new, and rapidly growing, area of study. As a practical, policy concern, it is also receiving much greater attention than has historically been the case. The book bridges gaps between literatures from a great range of sources, and brings together a wide span of discourses from policy, public and professional ethics, practice, and different academic disciplines. Its originality and importance come in its detailed, comprehensive analysis and definition of a new field of study, and its arguments for how the study of public health ethics is best undertaken. The book’s depth, breadth, and relevance make it stand out as an original contribution that will be of enduring relevance.

“The book’s chief strength is placing public health interventions, which are often seen as un- or a-political, firmly within a normative liberal framework, thereby exposing the value-loaded claims of a discipline that often sees itself as neutral or non-normatively scientific. The book makes a significant contribution to reflection on the normative basis of public health interventions. Nobody working in this field — the ethics and politics of public health interventions — can afford not to be familiar with it. It is excellent.”

The programme and list of awards winners can be read here.

 

Caroline Jones (John is far too modest to write this himself!).