Autonomy versus Public Health?

Autonomy and public health, do they match? The government now emphasises that Dutch people should decide themselves over their way of living, including health issues. Especially related to lifestyle, an increasing tension between autonomy and (public) health seems to be the case. This Spectrum explores this tension. Autonomy as being free from outside interventions is a very important notion in Western culture. With ongoing civilisation autonomy also became an ideal of those wanted to distinguish themselves from ‘the people’, those driven by lust and desires. This ideal of autonomy as an attitude of self control, regulation and monitoring fitted well to changes in governing, from sovereign visible power to people governing themselves. We obey rules from tooth brushing to eating to safe sex, often without realising we actually do. Autonomy came to mean an ideal, a way to live the good life.

With autonomy as freedom of thought and research, scientific and technical knowledge to apparently master the world came at hand. Health and disease changed from curse or chance to something that could be controlled. This lead to state coordinated interventions such as dikes and sewerage systems. The public’s health thus not only became a legitimate location for state action, this also made public health an instrument for ordering the social and containing chaos and moral decline as by-effects of industrialisation and urbanisation. The population appeared as a ‘problem’, an object of monitoring, regulation, analysis and intervention. Autonomy as self-control is here the individual side of the coin. And within prevention since the sixties, the autonomous rational individual cannot but autonomously follow scientific knowledge. Public health can thus also be seen as a way to turn people into responsible citizens: a good citizen lives healthy. Nowadays, autonomy seems to have moved from an ideal for a good life in a good society to ‘supermarket’-autonomy, from voice to choice. What to choose from and who that decides, stays out of sight, out of discussion.

The contribution of Matthijs van den Berg exemplifies how autonomy and public health intertwine and possibly conflict in screening programs, even in the official objectives. But why the increasing tension of today between autonomy and public health? Although for many health is very important, this is health as vitality, as wellness, as ‘positive’ health, often in stark contrast with public health’s focus on risk factors, on ‘negative’ health. Also, contemporary appreciation of so-called low culture in the media approves of letting go and living in the present, which does not match living your life as a project governing current actions in the light of future healthy results. Krispijn Faddegon’s contribution on nudging and overweight describes how to combine short and long term and to sustain both autonomy and health. In general, trust in scientific and government institutions seems fading, while at the same time in our knowledge society trust in experts appears necessary to live your life the way you want, as Lotte Asveld shows in her discussion of the HPV-vaccination. Defending autonomy solely in the consumentist tone does not increase trust since it is not geared at improving relations. This also means that discussing the healthy and good life and society, engaging in a moral learning process as argued for by Susanne Boomsma and Ruud Meij, will not be encouraged. However, making the relation between autonomy and public health less tense and more fruitful, requires such engagement: in a democracy personal tastes are not the end, but the beginning of the discussion.