Christian Munthe

In recent years a principle for responsible risk-taking called "The Precautionarity Principle" (PP) has been put forward in several policy documents regarding risk-management of technological and environmental issues. PP involves two claims: 1. An ethical claim according to which it is irresponsible to, for example, use new technologies, regdless of how large benefits these are known to bring, unless it has been proven that they will not give rise to unacceptable long term risks. 2. An administrative/political claim according to which the burden of supplying the proof spoken of in claim 1 is to be laid on the supplier of the new technology. This paper deals only with claim 1, which is the real "precautionarity claim". PP has produced much enthusiasm in different political circles, where it is often held out as a landmark for a new thinking in risk-management. However, while claim 2 is clear enough, it is rather obscure how the precautionarity claim is to be understood. In particular, it is not clear to what extent (if any) this claim implies anything new for risk-analysis. This is so since the precautionarity claim does not say anything about what is to be counted as a proof, or what constitutes an unacceptable risk. The paper explores different conlicting interpretations of the precautionarity claim and demonstrates how the choice between these actualise hard ethical issues. In particular, the issue of how much damage we are allowed to cause in order to pursue safety and certainty is discussed. This issue is actualized when new technologies with known beneficiary effects cannot be proven to be "safe enough" according to some interpretations of the precautionarity claim unless investigated for a rather long period of time, during which the technology is not allowed to be used to produce the beneficiary effects it can produce. This problem is structurally similar to a well known issue in medical ethics regarding the rsponsibility of continuing a controlled clinical trial of a drug known to cure when this means that half of the patients suffers extra agony and earlier death because they get a placebo instead of the new drug..

In patient-centred care, shared decision-making is advocated as the preferred form of medical decision-making. Shared decision-making is supported with reference to patient autonomy without abandoning the patient or giving up the possibility of influencing how the patient is benefited. It is, however, not transparent how shared decision-making is related to autonomy and, in effect, what support autonomy can give shared decision-making. In the article, different forms of shared decision-making are analysed in relation to five different aspects of autonomy: (1) self-realisation; (2) preference satisfaction; (3) self-direction; (4) binary autonomy of the person; (5) gradual autonomy of the person. It is argued that both individually and jointly these aspects will support the models called shared rational deliberative patient choice and joint decision as the preferred versions from an autonomy perspective. Acknowledging that both of these models may fail, the professionally driven best interest compromise model is held out as a satisfactory second-best choice.

While promoting population health has been the classic goal of public health practice and policy, in recent decades, new objectives in terms of autonomy and equality have been introduced. These different goals are analysed, and it is demonstrated how they may conflict severly in several ways, leaving serious unclarities both regarding the normative issue of what goal should be pursued by public health, what that implies in practical terms, and the descriptive issue of what goal that actually is pursued in different contexts. A basic conflict of perspective is handled by integrating the ideas of public health striving for health-related autonomy and equality, resulting in a prioritarian oriented population approach to health-related autonomy. This integrated goal is demonstrated to constrain itself in several ways attractive from the point of view of the classic goal, but several serious problems remain. For this reason, a model where all of the three goals are integrated into one coherent structure where they can be assigned varying degrees of importance relative to the level of population health is described. It is argued that this model avoids the problems set out earlier, and is actually normatively preferable to the classic goal alone. It is furthermore argued that the model may be employed as a useful tool for descriptive ethics, as well as a vehicle for international harmonisation of public health policies. A number of practical implications regarding, e.g., the importance of respecting autonomy and the allocation of public health resources are noted, as are a battery of questions for further research.