People with learning disabilities are subject to a wide range of potential interferences with their choices and freedoms when they are 'placed' in institutional care services. The cumulative and pervasive impact of these regimes can be monumentally detrimental to self and wellbeing. Some have suggested that a new law, the Mental Capacity Act 2005, may limit the interferences that people with disabilities are subject to in care services. In this thesis, I subject the Mental Capacity Act to a critique drawn from new republican political theory. I argue that far from limiting the interferences that people with disabilities are subject to, the Act creates a mechanism which permits a proliferation of arbitrary interferences in people's everyday lives, with little recourse for people to 'invigilate' such interferences. I base this argument on a critical analysis of case law connected to the Mental Capacity Act, and by critically examining four key mechanisms of enforcement: Independent Mental Capacity Advocates, the Court of Protection, complaints procedures and regulation by the Care Quality Commission. I argue that, paradoxically, a framework for detention introduced by the Act - the deprivation of liberty safeguards - in fact contains more ingredients for ameliorating states of domination in these services than the Mental Capacity Act itself. However, the safeguards also suffer from serious defects. I conclude by discussing what lessons may be drawn from the problems with the Mental Capacity Act and the safeguards for wider reform efforts connected with the UN Convention on the Rights of Persons with Disabilities.

Le recours aux soins est chose quotidienne pour l'ensemble des individus. Ces derniers sont effectivement soumis dans leur quotidien à la contrainte médicale émanant du "droit-créance" à la protection de la santé prévu à l'alinéa 11 du Préambule de la Constitution de 1946. Néanmoins, parallèlement à ce développement de l'accès aux soins, s'est dégagé le droit subjectif à la santé qui interdit toute atteinte à la santé de l'individu. Ces deux acceptions du droit à la santé interagissent au point que la première devienne une véritable contrainte pour la seconde. Il est donc indispensable de trouver des solutions afin qu'un équilibre puisse s'établir entre ces deux conceptions. Le consentement aux soins du patient constitue valablement une conséquence de la conception subjective du droit à la santé. Consacré par la loi du 04 mars 2002, relative aux droits des patients, le droit au consentement ne dispose d'aucun rattachement à une norme fondamentale opératoire, pour l'heure. Il se trouve en réalité souvent atteint par le recours imposé aux soins. Cette étude s'attache donc à démontrer que le droit au consentement aux soins présente une effectivité relative et qu'il est alors indispensable de le rattacher à des droits fondamentaux préexistant / The appeal(recourse) to the care is daily thing for all the individuals. The latter are actually subjected(submitted) in their everyday life(daily paper) to the medical emanating constraint of "right-claim"("right-debt","law-claim") in the protection of the health planned in the paragraph 11 of the Introduction of the Constitution of 1946. Nevertheless, in a parallel to(at the same time as) this development of the access to healthcare, got free the subjective right(law) for the health which forbids any infringement(achievement) on the health of the individual. These two meanings of a word of the right(law) for the health interact to the point that the first one(night) becomes a real constraint for second. It is thus essential to find solutions so that a balance can become established between these two conceptions(designs). The consent in the care of the patient establishes(constitutes) validly a consequence of the subjective conception(design) of the right(law) for the health. Dedicated by the law of March 04th, 2002, relative to the rights of the patients, the right(law) for the consent arranges no fastening with an operating fundamental standard, for the moment. He(it) is in reality often reached(affected) by the appeal(recourse) compulsory for the care. This study thus attempts to demonstrate that the right(law) for the consent in the care presents a relative effectiveness and that it is then essential to connect him(it) with pre-existent fundamental right

L’internationalisation de l’action publique sanitaire est aujourd’hui incontestable, et cette thèse représente une contribution intellectuelle à l’analyse de ce phénomène reconnu mais encore à explorer dans les détails. Partant d’un point très précis voire étroit, la substitution progressive dans le vocabulaire et les pratiques de l’Organisation mondiale de la Santé (OMS) de l’éducation sanitaire par la promotion de la santé, on retrace un parcours autrement considérable qui n’engage rien moins que les représentations historiques et politiques qui ont conduit à la mise en place de politiques publiques dans le domaine sanitaire, et ce à l’international. A la croisée de l’histoire des idées et de l’analyse des politiques publiques internationales, c’est une méthodologie innovante – articulant démarche intellectuelle et recherche empirique, notamment par l’observation participante et la conduite d’entretiens – que nous mobilisons pour retracer l’histoire et le fonctionnement réel de l’OMS.Notre travail se présente comme une histoire d’enchevêtrements de savoir(s), de jeux de pouvoir et de processus d’institutionnalisation dans des contextes changeants. Partant de l’émergence, dès le XVIIIe siècle, de l’éducation sanitaire comme stratégie visant la modification des comportements individuels puis de son inscription au sein de l’OMS, on en arrive à la question du changement de l’action publique (internationale). L’affirmation progressive de la promotion de la santé à partir des années 1980 traduit le travail de sens opéré par des acteurs (de l’OMS) qui, confrontés à des tensions liées à des modifications dans les équilibres jusqu’alors établis, modifient leurs discours et leurs pratiques afin de conserver, ou d’acquérir, une capacité à orienter l’action publique. Surtout, notre recherche montre que l’action publique sanitaire (internationale) se caractérise aujourd’hui par l’effort pour concilier – dans un contexte de complexification des enjeux, d’hétérogénéité croissante des savoirs et de multiplication des acteurs susceptibles d’intervenir au nom de la santé publique – des registres de légitimation (la défense de la liberté individuelle et la nécessité d’une action collective au nom de ce « bien commun » qu’est la santé) et des stratégies d’action (individuelles et collectives) non seulement différentes mais qui souvent même s’opposent. / This doctoral thesis is an intellectual contribution to the analysis of the unquestionable, process of internationalization of public health policies. Starting from a precise and even narrow point—the transition from “health education” to “health promotion” in the discourses and practices put forward by the World Health Organization (WHO)—we retrace the historical and political representations that shape public health-related policies at the international level. This interdisciplinary work, at the crossroad of the history of ideas and the international public policies analysis, is based on an innovating methodology which articulates an intellectual and empirical research to the analysis of the history and the functions of the WHO.This history is one of knowledge intertwining with games of power and institutional processes in shifting contexts. Starting with the emergence as early as the XVIIIth century of health education as a strategy for changing personal behaviors and its inclusion far later in the WHO structure, we move to the question of (international) public (health) policies transformations. The progressive affirmation of health promotion in the 1980’s reflects how WHO instances reframed the meaning of their work, when confronted to the tensions provoked by the shifting balance of well-established conceptions, and how they modified their discourse and their practice in order to keep or acquire a capacity to influence public action.. Above all, our research shows that (international) public health policies are today characterized by a attempt to combine—in a context of complexified issues and increased heterogeneity in knowledge as well as of a greater number of stakeholders in public health (action)—an array of legitimizing discourses ranging from the defense of individual freedom and the need for collective action on behalf of health as a “common good” to (individual and collective) strategies of action that are not only different but often conflicting.

Les infections nosocomiales sont définies comme des infections contractées lors d’un séjour dans un établissement de soins. En matière de sécurité sanitaire, celles-ci sont déterminées par le principe de prévention et de précaution. En droit français, les infections nosocomiales ont longtemps été indemnisées en conséquences de solutions prétoriennes. Ce régime indemnitaire repose aujourd'hui sur le principe de la responsabilité sans faute qui a été consacré par la loi du 4 mars 2002. Toutefois la difficile prise en charge de cette indemnisation par les assureurs conduisit à l’adoption d’un nouveau régime découlant de la loi du 30 décembre 2002. Ces lois successives ont rendu complexe et ambigu le mécanisme de la réparation des dommages causés par les infections nosocomiales. Le constat résulte du fait qu’il manque une définition juridique de l’infection nosocomiale, outil essentiel à la pérennité du système indemnitaire mis en place pour la réparation des dommages causés par ces infections. / Nosocomial infections are infections acquired during a stay in a health care institution. From the sanitary safety point of view, they are defined by the prevention principle and the precautionary principle. According to the French law, the nosocomial infections have long been compensated by a case law. Nowadays, this compensation system is based on the principle of liability without fault laid down by the law of the 4th of March 2002. However, the reluctance of the insurers to assume this compensation led to the adoption of a new system resulting from the law of the 30th of December 2002. Because of these successive laws, the compensation mechanism for the damages due to nosocomial infections has been made more complex and ambiguous. This observation stems from the lack of a legal definition of the nosocomial infection, an essential tool for ensuring the sustainability of the compensation system for the damages caused by these infections

Old age – and particularly the increasing numbers of older people globally and within the United Kingdom - is becoming a social and political phenomenon. Yet despite this, very little has been written on how the law – and especially mental disability law – intersects with old age. This is notwithstanding the fact that many older people may encounter conditions that impact their mental or cognitive abilities, and proportionally, may therefore be greatly affected by this area of law. By drawing on a number of theories – sometimes termed ‘relational’ theories – which are derived predominantly from feminist theory, this thesis seeks to explore the adequacy of mental disability law for safeguarding health and welfare-related decision-making of older adults in three areas; where an older person has been subjected to ageism, where they have been the victim of interpersonal abuse, and where they have dementia and may lack mental capacity. Within this broader goal, this thesis has two specific aims. First, to explicitly critique and challenge the adequacy of the law as it is applied in these circumstances. It is suggested in particular that a deeper analysis of the law in both its previous and current forms betrays the liberal and unduly individualistic roots of the legislative framework. These are roots that are predicated on non-interference, and an idealistic paradigm of the rational, autonomous, and healthy bodied individual. This – it is contended throughout – is an unsuitable philosophy to underpin the law, particularly where the law engages with older adults. Second, this thesis aims to navigate a more suitable pathway within the law as it currently exists. While operating as a tool to critique the legislative framework and its underpinning philosophy, it is argued that the theories drawn upon throughout the thesis also have the potential to highlight how the law could be implemented in such a way so as to emphasise the importance of the realities of the lived experiences of old age, and particularly the experience of ageism, abuse, and dementia. Crucially, it is also suggested that such theories can help the law pay greater attention to the complex web of relationships – both positive and negative; personal and societal – that an older person may find themselves embedded within, and that frequently take on an added significance in old age.

This thesis aims to provide a framework for analyzing the moral responsibilities of global agents in what I call the Global Health Crisis (GHC), with special attention devoted to the moral responsibilities of pharmaceutical companies. The main contribution of this thesis is to provide a general account of the moral responsibilities of different global players, mapping the different kinds of duties they have, their content and force, and their relation to the responsibilities of other relevant actors in the GHC. I also apply this account to current debates surrounding the need for reforms to the international legal rules addressing the GHC, notably the TRIPs regime. In doing so, this thesis will discuss the allocation of responsibilities for the GHC among different global players, such as state and non-state actors, the latter including pharmaceutical companies. In order to investigate the allocation of duties, I will first analyze the object of such allocation which constitutes the object of the current GHC (Part A); then the agents responsible for addressing this crisis (Part B); and finally, existing institutional alternatives to reform the international legal rules addressing the GHC, such as the TRIPs regime (Part C).

La e santé, la m-santé et la quantification de soi connectent le corps et bousculent le modèle traditionnel du soin. Ils le font glisser d’une médecine curative et monopolistique à une médecine préventive et adoptant une approche de la santé telle que définie par l’OMS. Par ce truchement, la personne n’est plus simplement placée au centre du dispositif de soin elle en devient l’un des acteurs y compris dans l’intimité de sa vie privée. Par ailleurs, sans cesse à la recherche de la réalisation d’économie mais aussi de qualité, le système de santé, a muté, sous l’effet du déploiement de l’e-santé. Il en résulte qu’il est désormais substantiellement décloisonné et ne peut plus être synthétisé dans la dichotomie classique entre le sanitaire et le médico-social. Le vecteur et la résultante de ce phénomène consiste dans la circulation de l’information de santé. Désormais majoritairement numérisée elle est devenue indispensable au soin ainsi qu’au fonctionnement du système de santé. Le soin est désormais conçu autour de l’échange et du partage catégoriel et inter-catégoriel, voire même homme-machine ou machine-machine et non plus sur une médecine fondée sur le secret. L’Homme devenu homo numericus n’en est pas pour autant dépourvu de tout droits et de toute intimité. Le droit et la techno-droit s’inscrivent dans ce jeu savant dont la moindre réforme inconséquente pourrait en bouleverser l’équilibre précaire / Health, m-health and self quantification connect the body and disrupt the traditional model of care. They are moving it from curative and monopoly medicine to preventive medicine and taking a WHO-defined approach to health. By this means, the person is no longer simply placed at the center of the care device he becomes one of the actors including in the intimacy of his privacy.On the other hand, in search of the realization of economy but also of quality, the health system, has mutated, under the effect of the deployment of e-health. As a result, it is now substantially landscaped and can no longer be synthesized into the classic dichotomy between health and social medicine. The vector and resultant of this phenomenon consists in the circulation of health information. From now on, it has become largely digital and essential for the care and functioning of the healthcare system. The care is now conceived around categorical and inter-categorical exchange and sharing, even man-machine or machine-machine and no longer on a medicine based on secrecy. The Man who has become a homo Numericus is not without all rights and privacy. Law and techno-law are part of this scholarly game, the slightest inconsistent reform of which could upset its precarious balance

Dans un contexte de vieillissement de la population, d’émergence de maladies nouvelles et d’accroissement des risques, la place de la santé dans le droit des obligations interroge. Retenue au stade de la formation du contrat lorsqu’elle influe sur les conditions essentielles de validité du contrat, la santé du cocontractant est-elle appréhendée, par la théorie générale des obligations, au stade de l’exécution ? C’est sous l’angle de l’altération de la santé que la question mérite d’être traitée. Cette notion, qui ne saurait se réduire à la maladie, va en effet permettre d’appréhender la modification de l’état initial de santé du cocontractant survenant pendant l’exécution du contrat, voire consécutivement à l’exécution même du contrat. C’est en réalité parce que la santé apparaît comme un élément du champ contractuel, tantôt révélé, tantôt consacré par le juge, que l’altération de la santé est prise en compte au stade de l’exécution du contrat. Lorsqu’elle vient perturber l’exécution contractuelle, le juge est amené à l’ériger en cause soit d’adaptation soit d’extinction du contrat. Dans l’hypothèse où l’exécution du contrat rejaillit sur la santé du cocontractant, l’appréhension de son altération va conduire à réparer, mais surtout préserver la santé de ce dernier. Les mécanismes tant contractuels qu’indemnitaires vont ainsi permettre de responsabiliser les contractants, participant alors à la prévention de l’altération de la santé consécutive à une exécution défectueuse du contrat. Aussi cette étude a-t-elle révélé que l’exécution du contrat est placée sous la dépendance de la santé. Si l’appréhension de l’altération de la santé se trouve théoriquement justifiée, ne devrait-elle toutefois pas être plus largement prise en compte ? Sans remettre en cause les fondements mêmes de l’appréhension de l’altération de la santé, diverses propositions sont formulées en ce sens. / In the context of population ageing, of new diseases emerging and of increasing risks, the role of health within contract law is questioned. The health of the contractor is considered at the formation of the contract when it influences the essential conditions of its validity. However, is the health of the party considered at the performance of the contract using the general theory of obligations? It is from the viewpoint of the alteration of health that the issue should be treated. This concept, which cannot merely be reduced to illness, will indeed allow to address the modification in the initial state of healthof the contractor during the performance of the contract, or even following its execution. It is actually because health appears as an element of the contract, either because it is revealed or because it is enshrined by the judge, that the alteration of health is taken into account at the stage of performance of the contract. When the alteration of health disrupts the performance of the contract, the judge raises it as a cause for adaptation or termination of contract. In the event the contract has an impact on the health of the contractor, the consideration of the alteration will lead to compensation but also to the protection of his health. Both contractual and indemnity mechanisms will enable contractors to be accountable, thus helping to prevent the alteration of health following a defective performance of the contract. This analysis also demonstrates that the performance of the contract depends upon the health of the contractor. If the consideration of the alteration of health appears theoretically justified, should it not be more widely taken into account? Without calling into question the foundations of the consideration of the alteration of health, various proposals are expressed to this end.

In 2005, the House of Commons (HoC) Health Committee produced a report on The Influence of the Pharmaceutical Industry – the first of its kind since 1914. The inquiry concluded that there were ‘over-riding concerns about the volume, extent and intensity of the industry’s influence, not only on clinical medicine and research but also on patients, regulators, the media, civil servants and politicians’, and stressed the need ‘to examine critically the industry’s impact on health to guard against excessive and damaging dependencies’ (HoC 2005, p. 97). It also noted that it is important to comprehensively analyse pharmaceutical regulation in order to ascertain whether there are systemic problems: In some circumstances, one particular item of influence may be of relatively little importance. Only when it is viewed as part of a larger package of influences is the true effect of the company’s activity recognised and the potential for distortion seen. The possibility that certain components of any such campaign are covert and their source undeclared is particularly worrying. (HoC 2005, p. 97) This study addresses this recommendation and was primarily conducted to examine whether recognised concerns are merely ad hoc or as a result of systemic flaws in the current system of pharmaceutical regulation. The work addresses a gap in the academic literature by drawing on the fragmented criticisms of the pharmaceutical industry in order to produce a model to illustrate how various stakeholders collaborate with drug companies to promote licensed products, and to explore the nature of the relationships between these elite stakeholders. The thesis begins with a literature review which determines who is involved in pharmaceutical regulation; how the regulatory system works; and explores the key role of communication in this process (Chapters 1 to 3). The recurrent theme is the neglect or exclusion of the patient/consumer, which leads to the development a model of intra-elite communication in drug regulation called Pharmaffiliation (Chapter 3). The thesis then looks for evidence to support or refute this model, using multiple methods (Chapter 4). Four case studies (with specific selection criteria) are chosen to test the model’s constructs and indicators (Chapters 5 to 8). The research uncovers systemic problems in the current system of pharmaceutical regulation which can ultimately harm the patient/consumer, and the implications of these findings are discussed (Chapter 9). Solutions on a micro-level include consumer involvement in decision making processes, which can be enhanced through public education and awareness campaigns and the instigation of public inquiries whenever drugs are withdrawn from the market (HoC 2005, p. 105). On a macro-level, however, this will involve critically exploring neoliberal capitalism and the empowerment of the citizenry (Street 2001).