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Individual Liberty and Medical Control
  1. Harry Lesser
  1. Centre for Philosophy, University of Manchester

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    Heta Häyry, Avebury Series in Philosophy, Ashgate, Aldershot, 1998, vi+102 pages, £29.95.

    This is a short but very interesting book, which repays study. It is essentially a defence and an application to medical ethics of the principle of liberty (page 12), that “the liberty …of competent, well-informed, free agents must be …maximally protected in matters which concern only or mainly themselves”. Adoption of this Millian principle, which is argued for in the introduction, along with the adoption of principles of equality (that the needs and interests of all should be taken into account) and of responsibility for the welfare of one's fellow beings, raises, it may be said, three questions: who is a person (and therefore to be taken into account); when is a person sufficiently competent, and when do people have to sacrifice some liberty to help or protect the welfare of others? Chapter 1 tackles the first of these questions, following the defence of the principle of liberty in the introduction; chapters two to four deal with issues raised by the second question—whether voluntary euthanasia should always be opposed on paternalistic grounds, whether a general programme of coercion in patients' own interests can be defended, and what form of health education is ethically justifiable; and chapters five to seven deal with issues involving the line between individual liberty and social welfare—preventive medicine, treatment of AIDS, and decision making on health issues.

    The weakest chapter is the first, which adopts the view of Harris, Singer and others that self consciousness defines personhood, so that to kill a non-self conscious being—for example. a fetus, or a person in a permanent vegetative state—is to do no wrong to that being. The problem is that no argument is given: there is only abuse of the alternative position—to suggest, on page 20, that those who take the potential personhood of the fetus seriously think that there is somehow an adult “in” the fetus, is ridiculous—and the pointing out of its dangers, such as making it impossible to justify abortion even to save life. But Häyry's view has the danger of giving us no reason for not killing neonates whose parents reject them: the issue cannot be settled in this way.

    The defence of “Mill's principle” is better, but still insufficiently argued, though space may have made this inevitable. Many good arguments are given, but full justice is not done to the opposing view, which is not simply “moralist”, but based on the ideas that: (a) “Millians” are working with too limited a notion of harm; (b) one cannot harm oneself without also harming others, and (c) even competent adults are not always the best judges of what will harm them. A defence of libertarianism must deal with these more subtle objections, and not only the cruder ones. Even these are sometimes caricatured: are we really supposed to believe that “many influential religions and conservative groups” have the “ultimate aim” of criminalising premarital sex (page 85)?!

    But the best of the book is in chapters two to seven. Chapter two does an excellent job of refuting the paternalist arguments against allowing voluntary euthanasia (this does not settle the issue, though, because there are various other arguments). Chapter three successfully refutes the arguments for medical paternalism as a general social policy: particularly impressive is the identification of emotional blackmail and dishonesty as being as coercive as legal or physical control. Chapter four is, regrettably, more sketchy, but makes a start in identifying the principles of a form of health education that incorporates respect for liberty and autonomy.

    Chapters five to seven, on issues to do with both individual liberty and social welfare, involve surveying the issues rather than pursuit of a sustained argument, even though many arguments are discussed. Chapter five demonstrates very well the number and complexity of issues raised by preventive measures. Chapter six sets out very clearly issues involved in meeting the needs both of those infected with AIDS and those who wish not to be infected. Chapter seven, in contrast, is an argument for liberal utilitarianism in medical decision making, as a framework that can combine meeting individual needs and the needs of society in a way that is impossible if a libertarian, socialist or communitarian framework is adopted. Once again the argument is skilful but too short, and fails to deal with opposing views in their most convincing form.

    Hence, the demerits of this book are that it ties liberalism too closely to a dubious theory of what a person is, and it is too short, so that neither the defence of the liberal principle nor its application is fully developed. The merit is that within these limits it makes a good argument for the principle of liberty and some real progress in showing how it should be applied in specific areas. In short, this is a valuable contribution to medical ethics which one may hope the author will develop further in future publications.

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