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Not to Be Sneezed at on the Possibility of Justifying Infectious Disease Control by Appealing to a Mid-Level Harm Principle

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Not to Be Sneezed at on the Possibility of Justifying Infectious Disease Control by Appealing to a Mid-Level Harm Principle Quaestiones Infinitae PUBLICATIONS OF THE DEPARTMENT OF PHILOSOPHY AND RELIGIOUS STUDIES UTRECHT UNIVERSITY VOLUME 75 © 2014, André Krom All rights reserved ISBN 978-94-6203-503-4 Cover: Digital illustration of hiv-virus in color background (Renjith Krishnan/123RF) People outside swine flu department in a hospital (yandscreators/123RF) Not to be sneezed at On the possibility of justifying infectious disease control by appealing to a mid-level harm principle Vrij besmettelijk Over de mogelijkheid om infectieziektebestrijding te rechtvaardigen met een beroep op een mid-level schadebeginsel (met een samenvatting in het Nederlands) Proefschrift ter verkrijging van de graad van doctor aan de Universiteit Utrecht op gezag van de rector magnificus, prof.dr. G.J. van der Zwaan, ingevolge het besluit van het college voor promoties in het openbaar te verdedigen op 9 januari 2014 des middags te 12:45 uur door André Krom geboren op 26 mei 1974 te Haarlem Promotoren: Prof.dr. M.F. Verweij Prof.dr. M. Düwell Dit proefschrift werd mede mogelijk gemaakt met financiële steun van ZonMw (Programma Ethiek en Gezondheid – dossiernummer 141010005). Voorwoord Ik heb een ander proefschrift geschreven dan ik aanvankelijk voor ogen had. En daar ben ik blij om. Dat de studie er anders uitziet dan verwacht, is mede te danken aan mijn twee promotoren, Marcel Verweij en Marcus Düwell. Als je promotoren er onderling een toch wat andere benadering van (toegepaste) ethiek op nahouden, word je voordurend blootgesteld aan krachten die je in verschillende richtingen trekken. Terwijl Marcus me steeds dieper de theorie in trok, stimuleerde Marcel me (ook) om aansluiting te vinden bij de praktijk van infectieziektebestrijding. Dat laatste moest ook wel; een belangrijk doel van het project “Infectious Disease Control and the Harm Principle” was namelijk om een bijdrage te leveren aan ethische reflectie in de praktijk. Mijn insteek – het verkennen van een brug tussen theorie en praktijk – zal deels terug te voeren zijn op de confrontatie met genoemde krachten. Ook mijn eerdere opleiding door Govert den Hartogh is er debet aan. Het is aan de lezer om te bepalen in hoeverre het is gelukt om een (niet al te wankele) brug te slaan tussen theoretische reflecties op het schadebeginsel, enerzijds, en de rechtvaardiging van concrete maatregelen tegen infectierisico’s, anderzijds. De gekozen methode brengt overigens zelf ook risico’s met zich mee. Het resultaat van een poging om theorie en praktijk te verbinden zou weleens kunnen zijn dat practici de studie te theoretisch vinden, terwijl het voor theoretici misschien juist te praktisch is. Er valt ongetwijfeld nog het nodige te zeggen om de voorgestelde verbinding tussen theorie en praktijk verder te verhelderen en te verstevigen. Ik ben tot hier gekomen. Ik wil om te beginnen Marcel en Marcus heel hartelijk danken voor hun inspirerende begeleiding. Marcus stelde me meestal één of twee vragen die – het zal de kenners niet verbazen – vaak de volgende vorm hadden: ‘Als je x zegt [vul hier een willekeurige stelling uit mijn proefschrift in], dan veronderstel je toch noodzakelijk y en z… Hoe rechtvaardig je die keuze?’ En had je eenmaal een aanzet tot een antwoord gevonden, dan begon het circus weer van voor af aan. In de gesprekken met Marcus ging het er soms stevig aan toe. Enig temperament kan Marcus Düwell niet ontzegd worden, en laat hij nou net geen voorstander zijn van een mid-level benadering in de toegepaste ethiek. Maar de gesprekken waren altijd respectvol – en dat is essentieel. Marcus’ vragen zijn van groot belang geweest voor de ontwikkeling van deze studie, vooral voor het uiteenzetten en onderbouwen van de methodologie (hoofdstuk 2). Ik ben hem i daarvoor zeer dankbaar. Het siert Marcus dat hij in het eindstadium van mijn promotieonderzoek heeft voorgesteld dat Marcel eerste promotor zou worden (toen ik Marcus er met een knipoog naar vroeg, bleek dat niet vanwege zijn weerstand tegen een mid-level benadering te zijn). Zette Marcus soms stevig in, de aanpak van Marcel was altijd heel voorzichtig. Dat ik even nodig had om mijn draai te vinden in onze gesprekken, zegt vermoedelijk vooral iets over mij (ik ben ook voorzichtig). Ik heb grote bewondering voor de manier waarop Marcel commentaar op de grote lijn van conceptversies van deze studie heeft weten te combineren met commentaar op detailniveau. Zijn commentaar was altijd opbouwend en to the point en heeft me enorm geholpen bij het nadenken over hoe theoretische reflectie op een constructieve manier verbonden zou kunnen worden met het onderbouwen van morele keuzes in de praktijk van infectieziektebestrijding. Ik ben Marcel daarvoor zeer dankbaar. Ik heb het ook als heel leerzaam en inspirerend ervaren om theoretisch onderzoek te kunnen combineren met een reeks casusbesprekingen met artsen en verpleegkundigen infectieziektebestrijding. Je hoort weleens dat promotieonderzoek een eenzaam traject is. Ik heb dat zelf niet (altijd) zo ervaren. Dat het project een praktisch deel had, heeft daar zeker aan bijgedragen. Alleen al de casusbesprekingen betekende samenwerking met 22 anderen. Ik ben iedereen die aan de besprekingen heeft meegedaan zeer dankbaar voor de mogelijkheid om (enig) inzicht te krijgen in de praktijk van infectieziektebestrijding en voor de mogelijkheid om onderdelen uit deze studie aan de praktijk te toetsen. Van deze groep wil ik graag twee mensen in het bijzonder bedanken. Allereerst Jim van Steenbergen (Centrum Infectieziektebestrijding, RIVM), die vanuit de samenwerking tussen het RIVM en het Ethiek Instituut bij alle casusbesprekingen was, en die met prikkelende stellingen elke discussie wist te verrijken. Ik ben hem ook zeer dankbaar voor zijn gedetailleerde commentaar op het medisch-technische deel van deze studie (hoofdstuk 1). Ook Babette Rump (GGD Midden-Nederland) wil ik hartelijk danken. Haar expertise op het gebied van infectieziekten, haar goede gevoel voor de ethische aspecten van infectieziektebestrijding, en haar enthousiasme over het project en mijn onderzoek waren inspirerend en een grote steun in de rug. Mijn promotieonderzoek had ook een sociaal karakter vanwege de inbedding in het Ethiek Instituut/ het departement wijsbegeerte van de Universiteit Utrecht. Ja, waar moet je dan beginnen? Ik begin bij de voordeur van het historische pand op Janskerkhof 13 en wil enkele ii mensen noemen die in de afgelopen jaren praktisch en/of inhoudelijk hebben bijgedragen aan mijn onderzoek: Biene Meijerman (dank!), links de trap op, Maarten van Houte, Mariëtte van den Hoven, Ineke Bolt, Carla Kessler, Franck Meijboom, Bernice Bovenkerk, Frans Stafleu, Robert Heeger, Suzanne van Vliet, Judith Zijm, Jan Vorstenbosch, Jos Philips, Micha Werner, Rob van Gerwen, Bert van den Brink, Joel Anderson, Dascha During (dank!), naar mijn oud- kamergenoten op de “onderzoekszolder” (je vraagt je af wat er in de rest van het gebouw gebeurt), Jos Kole, Gerhard Bos, Caroline Harnacke, Thomas Fossen, Frederike Kaldewaij, Annemarie Kalis, Katrien Schaubroeck, Nina van Heeswijk, Kirsten Pols, Clemens Driessen, Karianne Kalshoven, Teng Fei (Sally), Tom Wang, Liesbeth Feikema, Tatjana Visak en Jeroen Goudsmid. Laat ik uit een eerdere periode Niels Nijsingh, Paul Sollie en Bart Walhout niet vergeten (toen het Ethiek Instituut nog op de Uithof zat). Ik heb het altijd heel prettig en leerzaam gevonden om omringd te worden door zoveel aardige en slimme collega’s. Velen van jullie hebben de afgelopen jaren meerdere keren commentaar geleverd op onderdelen van mijn proefschrift, vaak tijdens de bespreking van een concepthoofdstuk in het colloquium praktische filosofie (in dat kader ook veel dank aan Ton van den Beld en Antoine Mooij). Ik heb de goedbezochte bijeenkomsten altijd als warm en waardevol ervaren. Velen van jullie hebben daarnaast de moeite genomen om schriftelijk te reageren op conceptstukken. Hartelijk dank voor al jullie vragen, tegenwerpingen en suggesties, en natuurlijk voor de gezelligheid! Sociaal promoveren betekent ook vaak samen lunchen, koffie drinken en/of borrelen. Concepten van de meeste hoofdstukken uit deze studie zijn gepresenteerd en bediscussieerd tijdens verschillende workshops en conferenties: zoals de jaarconferenties van de Onderzoekschool Ethiek (2009, 2011, 2012), workshops van de ethiek instituten uit Münster, Utrecht, Nijmegen, Tübingen en Zürich (Tübingen, 2010; Münster 2010), het World Congress of Bioethics (Singapore, 2010), een bijeenkomst van de onderzoeksgroep “Theoretische Grundfragen der Normenbegründung in Medizinethik und Biopolitik” (Münster, 2012), en de workshop “Time, Harm and Uncertainty – themes in the Ethics of Infectious Disease” die werd georganiseerd rond een verblijf in Londen als visiting scholar aan het Centre for Philosophy, Justice and Health (UCL, 2012). Ik dank een ieder die actief heeft deelgenomen aan deze bijeenkomsten hartelijk voor zijn/haar vragen en opmerkingen. Bijzondere dank gaat uit naar de volgende mensen: Govert den Hartogh voor een uitgebreide reactie op een artikel uit 2011 waarin ik enkele problemen bespreek rond een mid-level schadebeginsel in de infectieziektebestrijding iii (zie hoofdstuk 5); Thomas Gutmann voor de uitnodiging om twee concepthoofdstukken te presenteren in Münster (2012); Joel Anderson voor zijn gastvrijheid, de discussies en de gezelligheid tijdens mijn verblijf in Münster (2012); James Wilson voor het organiseren van een workshop en voor de goede zorgen en discussies tijdens mijn verblijf in Londen (2012); en tot slot Jasper Littmann en Michael Millar voor de discussies
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