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One of the most important intellectual strands in public health over the last century has been the development of a health and human rights approach. This approach reflects the understanding that health is inseparable from the social and political rights that support the dignity and autonomy of the individual and that efforts to improve health must engage with these factors. To my mind, a focus on human rights should be central to everything we do in public health.
Towards this aim, I suggest how we can recenter our engagement with human rights, to apply a better, more pragmatic human rights focus to our work. I will do so by addressing what has always seemed to me to be at the heart of a human rights approach—individual autonomy. Autonomy is defined as the quality or state of being self-governing. For the philosopher Immanuel Kant, autonomy meant our uniquely human capacity to make choices in accordance with our understanding of morality. In his writing about health and human rights, my colleague George Annas has addressed what a concern for autonomy in health means in practice—a focus on the right of patients to informed consent, including their right to refuse treatment. These perspectives all reflect the central role that individual autonomy should play in our understanding of health and human rights.
Now, in many ways, this poses a conundrum for our pursuit of healthy populations because much of what we talk about in public health is, in fact, about restricting individual autonomy. A classic example of this is speed limits. We impose limits on how fast we as individuals can get to where we want to go because we recognize that doing so keeps us safer, reducing the risk of injury and death. We are protecting people by limiting their autonomy. I have in the past engaged with public health’s embrace of such limits by addressing the difference between “freedom to” and “freedom from.” “Freedom to” is the freedom of the individual to do as she pleases, to live a rich, full life unencumbered by undue restrictions. “Freedom from” is the freedom to live without the threat of disease and preventable harm. “Freedom from” can, at times, depend on restrictions on individual autonomy. Yet the aim of these restrictions is to prevent an even greater restriction, the restriction caused by injury, disease, or death. This kind of restriction poses a far greater threat to our capacity to live our lives as we wish than rules and regulations.
Unfortunately, we have not always lived up to the responsibility of balancing respect for individual autonomy with the necessity of sometimes having to limit it. How can we fix this? First, we need to recognize that individual autonomy is at the core of much of the contemporary debate over public health. Our failings during COVID stemmed, in large part, from our hesitance to engage in this debate, to make the affirmative case for an approach to health that respects individual autonomy while also, yes, asking the public to make certain sacrifices to ensure as many people as possible can access the freedom health brings. We have, as a field, long let the foes of any public health restrictions set the terms of this debate, causing us to act defensively, to downplay what we ask of the public and pretend that the measures we call for are all but cost-free with respect to individual autonomy. In this post-war moment for health, we have an opportunity to reengage with these fundamental questions: “Yes, there are times when we must curtail individual autonomy, but we do so to support a vision of the common good aimed at maximizing freedom for all by supporting health for all.”
Second, we need to be judicious about when we are in favor of restricting autonomy. It will likely always be the case that we must sometimes call for policies that restrict “freedom to” to maximize “freedom from.” Yet just because this is sometimes necessary does not mean it is always necessary and we have a responsibility to keep this distinction in mind. In public health, we can find ourselves in positions of influence, supported by our science and the accumulated expertise of our field. This means that when we speak, we are often listened to, and our recommendations can quickly become policies that shape the lives of millions. Because we have this power, we should take care to use it only when it is necessary, and never more than the moment calls for.
Finally, we need to listen—really listen—to what those who wish to preserve their autonomy are saying. This echoes my last post, which addressed our engagement with values systems that may be different than our own. We need to understand that, in our zeal to prevent disease and harm, we are acting in accordance with a set of values that are not shared by all. This does not mean we should abandon our values, but it does mean that we have a responsibility to understand alternative perspectives and to better weigh the pros and cons of the actions we consider. We need to engage with a vision of human rights that balances individual autonomy with the pragmatic measures that are sometimes necessary to safeguard health by way of limiting—cautiously, temporarily—this autonomy. By listening to populations when they express concern about these limits, we can better define the scope of our efforts, shaping approaches that support health without unduly constricting what these populations can and cannot do. We can take the pragmatic steps we must sometimes take—calling for limits but only when absolutely necessary—while respecting the dignity of the populations we serve.
A version of this post also appears on Substack.
