Public health and private liberty is complexBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d7514 (Published 22 November 2011) Cite this as: BMJ 2011;343:d7514
- Vivienne Nathanson, director of professional activities1
Sokol assumes that Mill’s defence of individual liberty clarifies the scope of state responsibility to its citizens.1 It does not. In complex societies the distinction between harms to self and harms to others is unclear. If individual autonomy always trumped collective interests we would have no motorcycle helmet legislation, no seat belts, and no punitive taxation on harmful substances such as tobacco.
We thrive as autonomous individuals because of, not in spite of, collective social goods. The BMA’s public health work—its campaigns against smoking, alcohol misuse, and boxing—draws on the fundamental insight that a respect for autonomy requires attention to the conditions that make autonomy possible.
Somewhat tendentiously, Sokol suggests that the BMA’s call for a ban on boxing is linked to its “offensiveness,” implying that it is a matter of taste. It is based on medical evidence. In 2007, the BMA reviewed the evidence and reaffirmed its position. Injuries caused by boxing include:
Acute brain haemorrhage
Eye, ear, and nose damage.
Sokol rightly points out that the BMA unequivocally supports the right of competent patients to refuse medical treatment, even if refusal results in death. Treatment of such patients amounts to assault. Granted this is an argument from law not principle. Autonomy, however, is not a one size fits all principle. It is expressed differently in different contexts. Respecting refusal of treatment is based on the requirement to respect bodily integrity. It makes a very different demand on the principle than the “right” to take part in a sport aimed at the physical degradation of an opponent. To suggest that Mill’s harm principle is a “knock-out” reduces a matter of considerable public interest to philosophical triteness. It is Sokol’s simplistic appeal to the principle of autonomy that is confused, not the BMA.
Cite this as: BMJ 2011;343:d7514
Competing interests: VN is director of professional activities at the BMA.