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Public Deliberation and Strategic Leadership c h a p t e r f i v e Politically legitimate decisions about the use of coercion require not only the right kind of deliberation but also deliberation by the right people. Simply designating an amorphous “public” will hardly do. Where coercion is considered, it is important to determine who should have a right to input, where the authority for a final decision should lie, and what sorts of constraints should apply to this authority. Without question, these items will vary in different contexts. The most obvious qualification for a right to deliberative input is the likelihood that one will be affected by a proposed intervention. In clinical and organizational ethics, affected parties are often referred to as “stakeholders” and their interests (or “stakes”) in a given clinical decision are characterized, then roughly compared and contrasted. Decisional input from deeply affected parties generally carries more weight than input from those who are affected only peripherally. That is why, for instance, input from competent patients is accorded such a high priority—they are usually the ones most profoundly affected by medical interventions. A similar weighing of interests usually pertains in public health ethics and public policy. Just as medicine recognizes a principle of the autonomy of individual patients for medical treatment decisions, public health (sometimes) recognizes a principle of weighted autonomy of individuals, communities, and populations for decisions that affect their lives in a relatively exclusive way. Unfortunately, strong strains of paternalism also exist in public health practice. The recent attack on medical paternalism mounted by bioethicists and other scholarly critics never really extended into the territory of public health. Thus, public health officials painlessly lapse into thinking that health is an invariant universal value that is precisely understood only by experts, and that health promotion is such a serious, difficult, and complicated task that it should be closely overseen and controlled by experts such as themselves. I hope that the preceding chapters have dispatched this view. Our first concern now is to determine how stakeholders should be identified for participation in public deliberative processes in which coercion is proposed, a problem that frequently hinges on two types of concern: how interests should be weighted, and how deliberative bodies can be limited to workable sizes. These factors play out differently depending on the scope of anticipated effects, the simplest case being decisions for individual action that primarily affect the actor. right deliberators for self-regarding decisions The first, most obvious, and in many cases most compelling source of interest in coercive decisions is the interest inhering in those who will be objects of coercion. As we have observed, individuals typically have a strong prima facie interest in not being forced to surrender their autonomy. In clinical medicine, the prerogative for self-governance begets a virtually inviolable right of competent patients not to be touched or restrained against their will. Two sorts of general ethical criteria exist for abridging this liberty: (1) the patient is unable to make an informed decision (usually due either to impaired decisional capacity or to time constraints that preclude informed decision making), or (2) the result of not restraining the patient would probably be serious harm to the public’s health. Thus, we take seriously injured comatose patients to the operating room without their permission; and patients with certain infectious conditions (e.g., tuberculosis) are sometimes required to undergo directly observed treatment. As we will shortly observe, both of these general ethical criteria apply (albeit differently) in public health decisions about coercion. If we extend principles of clinical ethics to public health practice, we would rule out the prevention of self-harm (PSH) as a general rationale for coercive public health interventions—except where something like the two aforementioned abridgement criteria pertained (the second criterion actually hinges on PHO, the prevention of harm to others). Motorcycle helmet laws were earlier cited as an example of a public health intervention based on PSH. Both inadequate decisional capacity (motorcyclists not having the sophistication to understand risks) and harm to the public (covering bikers’ medical treatment) have been proposed as rationale for such laws; but (as we observed) these strained arguments function mostly as a cover for dismissive judgments about bikers’ conceptions of the good life. Seatbelt laws are a better example of justifiable legislation based on PSH. The harm to the 68 t h e e t h i c s o f c o e r...

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