It has become increasingly difficult to distinguish publichealth from related fields like social work. I argue that we should reclaim the more traditional conception of publichealth as the provision of health-related public goods. The public goods account has the advantage of establishing a relatively clear and distinctive mission for publichealth. It also allows a consensus of people with different comprehensive moral and political commitments to endorse public (...) class='Hi'>health measures, even if they disagree about precisely why they are desirable. (shrink)
It is often claimed that there is an obesity epidemic in affluent countries, and that obesity is one of the most serious publichealth threats in the developed world. I will argue that obesity is not an 'epidemic' in any useful sense of the word, and that classifying it as a publichealth problem requires us to make fairly controversial moral and empirical assumptions. While epidemiological evidence suggests that the prevalence of obesity is on the rise, (...) and that obesity can lead to serious health problems ranging from diabetes to cardiovascular disease, this does not by itself show that obesity is a publichealth problem. (shrink)
The recent confirmation of the constitutionality of the Obama administration’s Patient Protection and Affordable Care Act (PPACA) by the US Supreme Court has brought to the fore long-standing debates over individual liberty and religious freedom. Advocates of personal liberty are often critical, particularly in the USA, of publichealth measures which they deem to be overly restrictive of personal choice. In addition to the alleged restrictions of individual freedom of choice when it comes to the question of whether (...) or not to purchase health insurance, opponents to the PPACA also argue that certain requirements of the Act violate the right to freedom of conscience by mandating support for services deemed immoral by religious groups. These issues continue the long running debate surrounding the demands of religious groups for special consideration in the realm of health care provision. In this paper I examine the requirements of the PPACA, and the impacts that religious, and other ideological, exemptions can have on publichealth, and argue that the exemptions provided for by the PPACA do not in fact impose unreasonable restrictions on religious freedom, but rather concede too much and in so doing endanger publichealth and some important individual liberties. (shrink)
This paper presents a novel view of the concept of cognitive enhancement by taking a population health perspective. We propose four main modifiable healthy lifestyle factors for optimal cognitive functioning across the population for which there is evidence of safety and efficacy. These include i) promoting adequate sleep, ii) increasing physical activity, iii) encouraging a healthy diet, including minimising consumption of stimulants, alcohol and other drugs including nicotine, iv) and promoting good mental health. We argue that it is (...) not ethical to promote or sanction the use of pharmaceutical drugs as putative cognitive enhancers without acknowledging the adverse effects on population cognitive health of failing to encourage the pursuit of healthy behaviours. We conclude with recommendations to increase the publichealth relevance of bioethical analyses of the cognitive enhancement debate. (shrink)
Targeting high-risk populations for publichealth interventions is a classic tool of publichealth promotion programs. This practice becomes thornier when racial groups are identified as the at-risk populations. I present the particular ethical and epistemic challenges that arise when there are low-risk subpopulations within racial groups that have been identified as high-risk for a particular health concern. I focus on two examples. The black immigrant population does not have the same hypertension risk as US-born (...) African Americans. Similarly, Finnish descendants have a far lower rate of cystic fibrosis than other Caucasians. In both cases the exceptional nature of these subpopulations has been largely ignored by the designers of important publichealth efforts, including the recent US government dietary recommendations. I argue that amending the publicly-disseminated risk information to acknowledge these exceptions would be desirable for several reasons. First, recognizing low-risk subpopulations would allow more efficient use of limited resources. Communicating this valuable information to the subpopulations would also promote truth-telling. Finally, presenting a more nuanced empirically-supported representation of which groups are at known risk of diseases (not focusing on mere racial categories) would combat harmful biological race essentialist views held by the public. (shrink)
The study of threat and fear appeal arguments has given rise to a sizeable literature. Even within a publichealth context, much is now known about how these arguments work to gain the public’s compliance with health recommendations. Notwithstanding this level of interest in, and examination of, these arguments, there is one aspect of these arguments that still remains unexplored. That aspect concerns the heuristic function of these arguments within our thinking about publichealth (...) problems. Specifically, it is argued that threat and fear appeal arguments serve as valuable shortcuts in our reasoning, particularly when that reasoning is subject to biases that are likely to diminish the effectiveness of publichealth messages. To this extent, they are rationally warranted argument forms rather than fallacies, as has been their dominant characterization in logic. (shrink)
Obesity has been described as pandemic and a publichealth crisis. It has been argued that concerted research efforts are needed to enhance our understanding and develop effective interventions for the complex and multiple dimensions of the health challenges posed by obesity. This would provide a secure evidence base in order to justify clinical interventions and public policy. This paper critically examines these claims through the examination of models of publichealth and public (...)health ethics. I argue that the concept of an effective publichealth intervention is unclear and underdeveloped and, as a consequence, normative frameworks reliant on meeting the effectiveness criterion may miss morally salient dimensions of the problems. I conclude by arguing for the need to consider both an ecological model of publichealth and inclusion of a critical publichealth ethics perspective for an adequate account of the publichealth challenges posed by obesity. (shrink)
Several recent anti-obesity campaigns appear to embrace stigmatization of obese individuals as a publichealth strategy. These approaches seem to be based on the fundamental assumptions that (1) obesity is largely under an individual’s control and (2) stigmatizing obese individuals will motivate them to change their behavior and will also result in successful behavior change. The empirical evidence does not support these assumptions: Although body weight is, to some degree, under individuals’ personal control, there are a range of (...) biopsychosocial barriers that make weight regulation difficult. Furthermore, there is accumulating evidence that stigmatizing obese individuals decreases their motivation to diet, exercise, and lose weight. Publichealth campaigns should focus on facilitating behavioral change, rather than stigmatizing obese people, and should be grounded in the available empirical evidence. Fundamentally, these campaigns should, first, do no harm. (shrink)
This paper defends a distinctly liberal approach to publichealth ethics and replies to possible objections. In particular, I look at a set of recent proposals aiming to revise and expand liberalism in light of publichealth's rationale and epidemiological findings. I argue that they fail to provide a sociologically informed version of liberalism. Instead, they rest on an implicit normative premise about the value of health, which I show to be invalid. I then make (...) explicit the unobvious, republican background of these proposals. Finally, I expand on the liberal understanding of freedom as non-interference and show its advantages over the republican alternative of freedom as non-domination within the context of publichealth. The views of freedom I discuss in the paper do not overlap with the classical distinction between negative and positive freedom. In addition, my account differentiates the concepts of freedom and autonomy and does not rule out substantive accounts of the latter. Nor does it confine political liberalism to an essentially procedural form. (shrink)
Is it possible to interfere with individual decision-making while preserving freedom of choice? The purpose of this article is to assess whether ‘libertarian paternalism’, a set of political and ethical principles derived from the observations of behavioural sciences, can form the basis of a viable framework for the ethical analysis of publichealth interventions. First, the article situates libertarian libertarianism within the broader context of the law and economics movement. The main tenets of the approach are then presented (...) and particular attention is given to its operationalization through the notion of a ‘nudge’. Essentially, a ‘nudge’ consists in an intervention, which aims to suggest one choice over another by gently steering individual choices in welfare-enhancing directions yet without imposing any significant limit on available choices. Finally, the article concludes that, while it fails as an overreaching framework of ethical analysis, libertarian paternalism nonetheless constitutes a valuable addition to the conceptual toolbox of publichealth ethics. (shrink)
Boehl Chair of Law and Medicine and Director of the Institute for Bioethics, Health Policy and Law, University of Louisville School of Medicine, 501 East Broadway # 310, Louisville, Kentucky 40202, USA. Tel.: 502 852 4980; Fax: 502 852 4963; Email: mark.rothstein{at}louisville.edu ' + u + '@' + d + ' '//--> Abstract In his article in this issue, Daniel Goldberg advocates a broad definition of publichealth and expressly rejects the narrow definition of public (...) class='Hi'>health I proposed in a 2002 article. Goldberg asserts that publichealth should include all of the root causes of ill health in populations. Such a definition, however, would include within publichealth war, famine, crime, illiteracy and numerous other conditions on which publichealth professionals and agencies lack the resources, expertise and public support to act. The appropriate definition explicitly recognizes that publichealth is a legal term of art referring to specifically authorized activities by public officials to protect, promote and improve population health. CiteULike Connotea Del.icio.us What's this? (shrink)
Many legal scholars well recognize that, in some instances, support for a law or policy may be primarily because of its expressive function, i.e. the statements it makes about underlying values. In these cases, the expressive content of a law or policy may actually overshadow its central purpose. Examples of this phenomenon, according to Cass Sunstein, include, for example, regulations against hate speech in the USA. He suggests that achieving the consequence (prohibiting hateful speech against certain groups) may not be (...) the real focus (central purpose) of the law. Rather, the real focus is on the social meaning of these regulations—that bigotry is unacceptable in a liberal society. In this way, a particular law or policy can operate on many levels—while aiming to achieve a particular objective or behavior, it can also be a valuable tool for achieving other important social goals through its expressive function. This article applies this insight to the realm of publichealth policy, with particular attention to the case of pandemic planning, and suggests that publichealth policy and its overall goals may be well-served by deliberate regard for, and appropriate utilization of, the expressive function. (shrink)
No provision of the Patient Protection and Affordable Care Act (PPACA) has been more contentious than the so-called “individual mandate,” the constitutionality of which is now before several appellate courts. Critics claim that the mandate represents an unprecedented attempt by the federal government to compel individual action. Yet, states frequently employ similar mandates to protect the public's health. These publichealth mandates have also often aroused deep opposition. This essay situates PPACA's mandate, and the opposition to (...) it, in that broader context. The article reviews the arguments that publichealth's population perspective provides in support of mandates, as well as the reasons why mandates often ignite intense legal and political opposition. Most importantly, by holding individuals accountable for population-based problems, mandates may undercut the publichealth arguments that justify them. The article concludes by arguing that publichealth policymakers need to know more about the unintended political and legal costs of mandates. (shrink)
American healthcare -- Bioterror and bioart -- State of emergency -- Licensed to torture -- Hunger strikes -- War -- Cancer -- Drug dealing -- Toxic tinkering -- Abortion -- Culture of death -- Patient safety -- Global health -- Statue of security -- Pandemic fear -- Bioidentifiers -- Genetic genocide.
Partly in response to rising rates of obesity, many governments have published healthy eating advice. Focusing on health advice related to the consumption of animal products (APs), I argue that the individualistic paradigm that prevails must be replaced by a radically new approach that emphasizes the duty of all human beings to restrict their negative “Global Health Impacts” (GHIs). If they take human rights seriously, many governments from nations with relatively large negative GHIs—including the Australian example provided here—must (...) develop strategies to reduce their citizens’ negative GHIs. As the negative GHIs associated with the consumption of many APs are excessive, it is my view that many governments ought to adopt a qualified ban on the consumption of APs. (shrink)
Increases in international travel and migratory flows have enabled infectious diseases to emerge and spread more rapidly than ever before. Hence, it is increasingly easy for local infectious diseases to become global infectious diseases (GIDs). National governments must be able to react quickly and effectively to GIDs, whether naturally occurring or intentionally instigated by bioterrorism. According to the World Health Organisation, global partnerships are necessary to gather the most up-to-date information and to mobilize resources to tackle GIDs when necessary. (...) Communicable disease control also depends upon national publichealthlaws and policies. The containment of an infectious disease typically involves detection, notification, quarantine and isolation of actual or suspected cases; the protection and monitoring of those not infected; and possibly even treatment. Some measures are clearly contentious and raise conflicts between individual and societal interests. In Europe national policies against infectious diseases are very heterogeneous. Some countries have a more communitarian approach to publichealth ethics, in which the interests of individual and society are more closely intertwined and interdependent, while others take a more liberal approach and give priority to individual freedoms in communicable disease control. This paper provides an overview of the different policies around communicable disease control that exist across a select number of countries across Europe. It then proposes ethical arguments to be considered in the making of publichealthlaws, mostly concerning their effectiveness for publichealth protection. (shrink)
The Patient Protection and Affordable Care Act of 2010 (ACA) contains many provisions intended to increase access to and lower the cost of health care by adopting publichealth measures. One of these promotes the use of at-work wellness programs by both providing employers with grants to develop these programs and also increasing their ability to tie the price employees pay for health insurance for participating in these programs and meeting specific health goals. Yet despite (...) ACA's specific alteration of three different statues which had in the past shielded employees from having to contribute to the cost of their health insurance based on their achieving employer-designated health markers, it chose to leave alone recently enacted rules implementing the Genetic Non-Discrimination Act (GINA), which prohibits employers from asking employees about their family health history in any context, including assessing their risk for setting wellness targets. This article reviews how both the changes made by ACA and the restrictions recently put place by GINA will affect the way employers are likely to structure Wellness Programs. It also considers how these changes reflect the competing social goals of both ACA, which seeks to expand access to the population by lowering costs, and GINA, which seeks to protect individuals from discrimination. It does so by analyzing both positive theories about how these new laws will function and normative theories explaining the likelihood of future friction between the interests of the population of the United States as a whole who are in need of increased and affordable access to health care, and of the individuals living in this country who risk discrimination, as science and medicine continue to make advances in linking genetic make-up to risk of future illness. (shrink)
University of Utrecht, Department of Philosophy, Heidelberglaan 6, 3584 CS Utrecht, The Netherlands. Tel.: +31 (0)30 253 28 74, Email: Thomas.Nys{at}phil.uu.nl ' + u + '@' + d + ' '//--> Abstract Measures in publichealth care (PHC) seem vulnerable to charges of paternalism: their aim is to protect, restore, or promote people's health, but the public character of these measures seems to leave insufficient room for respect for individual autonomy. This paper wants to explore (...) three challenges to these charges: (i) Measures in PHC are aimed to protect, restore or promote ‘deep autonomy’, (ii) Measures in PHC are directed at the public and, as such, they do show respect for autonomy, and (iii) Some measures in PHC can be justified on grounds of justice and need not be defended as cases of ‘justified paternalism’. Although charges of unjustified paternalism in PHC might still be relevant, we should at least face these different challenges. CiteULike Connotea Del.icio.us What's this? (shrink)
According to Stephen Holland, the challenges I mention in my original paper can be met, so that, in a way, the problem of paternalism in publichealth care—which I intended to put into perspective by drawing out some possible justifications for it—returns in all its might and glory. But of course, as Holland observes, I never suggested that my challenges could never be met. I only wanted to point out that for each and every particular public (...) class='Hi'>health policy that should come to our attention we should reflect upon these challenges and see whether they could provide reasons for justification. I believe that the discussion is often stalled because these measures—in the absence of individual consent and in their aim to benefit the public's ‘best interests’—seem to be paternalist by default. In my paper, I wanted to call this assumption into question, but never intended to prove that there is no such thing as unjustified paternalism in publichealth care. Nevertheless, Holland's criticism is very insightful and he has done a lot to clarify my position. However, he also puts me on the spot by urging me to argue to what extent I can meet his rebuttal, and I am very grateful for that opportunity. (shrink)
oise Baylis, 1234 Le Marchant Street, Halifax, Nova Scotia, Canada B3H 3P7. Tel.: (902)-494–2873; Fax: (902)-494-2924; Email: francoise.baylis{at}dal.ca ' + u + '@' + d + ' '//--> . Abstract Recently, there has been a growing interest in publichealth and publichealth ethics. Much of this interest has been tied to efforts to draw up national and international plans to deal with a global pandemic. It is common for these plans to state the importance of (...) drawing upon a well-developed ethics framework and we argue that this framework should reflect the values and insights of feminist relational theory. More specifically, we argue that pandemic planning must be squarely situated in the larger realm of publichealth and that an ethics framework for publichealth will be one that recognizes the need to pay particular attention to the vulnerability of subpopulations lacking in social and economic power. We propose an ethics framework for publichealth that builds on the notions of relational personhood (including relational autonomy and social justice) and relational solidarity. In this way, we aim for a publichealth ethics that, as appropriate, promotes the public interest and the common good. CiteULike Connotea Del.icio.us What's this? (shrink)
Center for Humans and Nature, 109 West 77th Street, Suite 2, New York, NY 10024, USA. Tel.: 212 362 7170; Fax: 212 362 9592; Email: brucejennings{at}humansandnature.org ' + u + '@' + d + ' '//--> . Abstract A fundamental question for the ethical foundations of publichealth concerns the moral justification for limiting or overriding individual liberty. What might justify overriding the individual moral claim to non-interference or to self-realization? This paper argues that the libertarian justification for (...) limiting individual liberty known as the ‘harm principle’ or the ‘Millian paradigm’ is inadequate as a basis of publichealth ethics and policy. But simply pitting some collectivist value or utilitarian criterion over against individual liberty is not theoretically satisfactory, either. John Stuart Mill himself was not a Millian, in this sense, and his utilitarianism does not pit itself against individual liberty as a situation of balancing conflicting values. A reconsideration of Mill, particularly in light of the later work of Berlin on liberty, points toward a conception of relational liberty that is crucial for publichealth ethics because it contains within itself the basis for its own moral limitation. CiteULike Connotea Del.icio.us What's this? (shrink)
Centre for Applied Philosophy and Public Ethics (CAPPE), The Australian National University, LPO Box 8260, ANU, Canberra ACT 2601, Australia. Email: michael.selgelid{at}anu.edu.au ' + u + '@' + d + ' '//--> . Home page: http://www.cappe.edu.au/staff/michael-selgelid.htm Abstract This article advocates the development of a moderate pluralist theory of political philosophy that recognizes that utility, liberty and (...) equality are legitimate, independent social values and that none should have absolute priority over the others. Inter alia, such a theory would provide a principled means for striking a balance, or making trade-offs, between these values in cases of conflict. Recent developments in publichealth ethics have made progress in thinking about how to make trade-offs between liberty and utility in particular. While publichealth ethicists often claim that the least restrictive alternative should be used to achieve the publichealth goal in question, I argue that a plausible but under-recognized idea is that the least restrictive alternative might sometimes involve improvement of global health via redistributive taxation—i.e., rather than coercive social distancing measures. I conclude by demonstrating that the proportionality principle leaves open the question of when exactly utility outweighs liberty or vice versa—and I argue that, rather than speaking about the morality of liberty-infringing publichealth interventions in categorical/binary terms, it would be more fruitful and realistic to think and speak about the degree to which a liberty-infringing publichealth intervention is morally appropriate. CiteULike Connotea Del.icio.us What's this?. (shrink)
Evaluating publichealth measures is one of the central tasks in publichealth ethics. Some publichealth measures incur the charge that they are paternalistic in an objectionable way. In a recent intriguing contribution to this journal, Thomas Nys responds to this complaint by setting out three challenges to be met if the charge is to be made good. The first challenge is that putatively objectionable publichealth measures in fact preserve autonomy; (...) the second is that autonomy is not undermined by measures that are the upshot of democratic processes; the third is that it is a mistake to charge measures intended to benefit others with being objectionably paternalistic. Nys's explicit aim in presenting these challenges is not to show that the charge of paternalism in publichealth is never sound, but to stimulate further discussion. My paper takes up this invitation by responding to each of the challenges Nys presents, including discussing where they fail and identifying which succeed. (shrink)
In this article, we analyse content from two recent reports to examine how a publichealth framework to cognitive enhancement is emerging. We find that, in several areas, these reports provide population-level arguments both for and against the use of cognitive enhancers. In discussing these arguments, we look at how these reports are indicative of potentially innovative frameworks—epidemiological, risk/benefit and socio-historical—by which to explore the publichealth impact of cognitive enhancement. Finally, we argue that these reports (...) are suggestive of both tensions between the bioethical and publichealth approaches and are also indicative of how these two frameworks can, in part, be seen as complementary. (shrink)
If ‘community’ is the answer, what is the problem? While questions undoubtedly arise in allocating resources to publichealth, such as ‘how much?’ and ‘to whom?’, we already have answers based on (i) the observation that disease and illness are bad, (ii) views of justice and fairness and (iii) an appreciation of market failure. What does the concept of community add to the existing answers? Not nothing, I shall argue, but not much either. In some cases, health (...) providers should take advantage of ties of community to deliver services more effectively. The desire to preserve communities may have some minor implications for devolved health care funding. The value of community may set some limits to inequalities in access to health care. That’s about it. I do consider some other claims of behalf of the concept, e.g. that people would not support justice in health care without a sense of community; but I don’t find these claims very plausible. Finally, I point out some ways in which communities can be damaged by the promotion of publichealth understood as population health. (shrink)
Corresponding Author, Health Policy & Ethics Fellow, Chronic Disease Prevention & Control Research Center, Department of Medicine, Baylor College of Medicine, 1709 Dryden, Suite 1025, Houston, TX 77030, USA. Tel.: 713.798.5482; Fax: 713 798 3990; Email: danielg{at}bcm.edu ' + u + '@' + d + ' '//--> . Abstract This article defends a broad model of publichealth, one that specifically addresses the social epidemiologic research suggesting that social conditions are primary determinants of health. The article (...) proceeds by critiquing one of the strongest arguments in favor of a narrow model, advanced by Mark Rothstein. The critique sets up the argument that a model of publichealth that does not address what actually causes health and disease is unlikely to improve publichealth. Assessing the substantial evidence regarding the social determinants of health, the article engages the policy paradox that precludes utopian prescriptions but demands more than mere expedience. CiteULike Connotea Del.icio.us What's this? (shrink)
Making research data readily accessible during a publichealth emergency can have profound effects on our response capabilities. The moral milieu of this data sharing has not yet been adequately explored. This article explores the foundation and nature of a duty, if any, that researchers have to share data, specifically in the context of publichealth emergencies. There are three notable reasons that stand in opposition to a duty to share one’s data, relating to: (i) data (...) property and ownership, (ii) just distribution of benefits and burdens and (iii) the contemporary ethos of science. We argue each reason can be successfully met with corresponding rationale in favour of data sharing. Further support for data sharing has been echoed in policies of health agencies, funding bodies and academic institutions; in documents on the ethical conduct of biomedical research; and in discussions on the nature of publichealth. From this, we ascertain that sharing data is the morally sound default position. This article then highlights the key roles reciprocity and solidarity play in supporting the practice of data sharing. We conclude with recommendations to regard publichealth research data as a common-pool resource in order to build a framework for stable data sharing management. (shrink)
Some theorists, worried about liberalism’s potential as a foundation for publichealth ethics, suggest that republicanism provides a better background of justification for publichealth policies, interventions, etc. In this article, this suggestion is put to the test, and it is argued that (i) contemporary (civic) republicanism and liberalism are not nearly as opposed as it is sometimes suggested, and that (ii) the kind of republicanism which one leading scholar in the field, Bruce Jennings, as an (...) alternative to liberalism, does not reflect the contemporary understanding of republicanism as held by, e.g. Phillip Pettit et al. (shrink)
Nuffield Council on Bioethics, London * Corresponding author: Nuffield Council on Bioethics, 28 Bedford Square, London WC1B 3JS, UK. Email: hschmidt{at}nuffieldbioethics.org ' + u + '@' + d + ' '//--> Abstract In November 2007, the Nuffield Council on Bioethics published the report PublicHealth: Ethical Issues . While the report has been welcomed by a wide range of stakeholders, there has also been some criticism. First, it has been suggested that it is not clear why, in developing (...) its ‘stewardship model’, the Council felt the need to go beyond the liberal position developed by John Stuart Mill—what is it that the stewardship model adds? Second, it is suggested that the Report is confused about the concept of paternalism. Third, it is argued that the discussion of the concept of stewardship is lacking in detail and substance. We clarify the Working Party's thinking regarding these three areas, which demonstrates the robustness of the framework set out in the report. CiteULike Connotea Del.icio.us What's this? (shrink)
Finding an effective microbicide that could substantially lower women’s risk of acquiring HIV infection is an ethical imperative. Women and girls continue to be disproportionally affected by HIV in sub-Saharan Africa. Ethics guidelines for conducting preventive HIV microbicide trials call for steps that intertwine biomedical research and publichealth. Ethical considerations include adequate studies of the safety of microbicides, the use of placebo controls in future trials once a microbicide is shown to be effective, whether leftover microbicide from (...) a trial that demonstrated efficacy should be made available to the public or used in the control group of a future trial, what preventive measures and treatment should be provided for trial participants during and after the research, and what constitute ‘fair benefits’ to the community or country when a trial is completed. The Global Campaign for Microbicides conducted a study of the benefits being provided to participants in microbicide trials and others, and found substantial evidence that researchers and sponsors are meeting the obligations stated in ethical guidelines. A cautionary tale of an HIV prevention trial that was prematurely halted demonstrates the need for engagement with the community where trials are carried out. (shrink)
Dr Thomas Stockmann, the protagonist of Ibsen's play, An Enemy of the People , discovers a serious health threat in the Baths of his Norwegian town. The Baths have been marketed as a health resort to lure visitors. Dr Stockmann alerts officials about the problem and assumes that they will close the Baths until it is corrected. He is met with fierce resistance, however. His brother, the town's mayor, favors keeping the Baths open and correcting the problem gradually. (...) He advances multiple arguments that appeal to the economic interests of the town and Thomas's role-related obligation as a citizen. His wife, Katherine, wants him to cooperate with the mayor. She marshals several arguments that appeal to his obligations as a father. This paper reconstructs and examines the competing arguments, shows how Ibsen's play has both contemporary relevance and moral depth, and demonstrates how Dr Stockmann's responses can be interpreted as an argument that complying with his duties to protect the publichealth do not force him to renege on his core commitments as a parent and as a citizen. (shrink)
Obesity is a publichealth problem influenced by behavioral patterns that span an ecological spectrum of individual-level factors, social network factors and environmental factors. Both individual and environmental approaches necessarily include significant influences from social networks, but how and under what conditions social networks influence behavior change is often not clearly mapped out either in the obesity literature or in many intervention designs. In this paper, we provide an analysis of recent empirical work in obesity research that explicates (...) social network influences on eating behaviors. We argue that a relational rather than individualistic view of personhood should help us better understand the content and context of social network relations that inform health behavior choices. We introduce the concept of ‘identity-constitutive affiliations’ as the glue that binds these social relationships together. Finally, we outline the implications for publichealth ethics in the development of effective interventions to address overweight and obesity, leveraging the content and context of social network ties to reinforce healthy (or alter unhealthy) eating. More complex treatment of positive and negative behaviors stemming from social network connections should lead to more comprehensive theoretical models of health behavior change and more effective publichealth interventions. (shrink)
There is a growing movement to increase access to palliative care by declaring it a human right. Calls for such a right—in the form of articles in the healthcare literature and pleas to the United Nations and World Health Organization—rarely define crucial concepts involved in such a declaration, in particular ‘palliative care’ and ‘human right’. This paper explores how such concepts might be more fully developed, the difficulties in using a human rights approach to promote palliative care, and the (...) relevance of such an enterprise to publichealth ethics. (shrink)
In this article, we address the relevance of J.S. Mill’s political philosophy for a framework of publichealth ethics. In contrast to some readings of Mill, we reject the view that in the formulation of public policies liberties of all kinds enjoy an equal presumption in their favor. We argue that Mill also rejects this view and discuss the distinction that Mill makes between three kinds of liberty interests: interests that are immune from state interference; interests that (...) enjoy a presumption in favor of liberty; and interests that enjoy no such presumption. We argue that what is of focal importance for Mill in protecting liberty is captured by the essential role that the value of self-determination plays in human well-being. Finally, we make the case for the plausibility of a more complex and nuanced Millian framework for publichealth ethics that would modify how the balancing of some liberty and publichealth interests should proceed by taking the thumb off the liberty end of the scale. Mill’s arguments and the legacy of liberalism support certain forms of state interference with marketplace liberties for the sake of publichealth objectives without any presumption in favor of liberty. (shrink)
This article draws on scientific explanations of obesity to motivate the creation of a system of paternalistic publichealth interventions into the obesity epidemic. Libertarian paternalists argue that paternalism is warranted in light of the cognitive limits of human decision-making abilities. There are further, specific biological limits on our capacity to choose and maintain a healthy diet. These biological facts strengthen the general motivation for libertarian paternalism. As a consequence, the creation of a system of paternalistic public (...)health interventions into the obesity epidemic is warranted. (shrink)
The Harvard University Program in Ethics and Health, 651 Huntington Avenue, 6th floor c/o HSPH, François Xavier Bagnoud Building, Boston, MA 02115, USA. Tel.: +1 617 4327244; Email: andras_miklos{at}hms.harvard.edu ' + u + '@' + d + ' '//--> Abstract When exercising their publichealth powers, states claim various rights against their subjects and aliens. The paper considers whether publichealth considerations can help justify some of these rights, and explores some constraints on the justificatory (...) force of publichealth considerations. I outline two arguments about the moral grounds for states’ rights with regard to publichealth. The principle of fairness emphasizes that those who benefit from publichealth measures ought to contribute their fair share in upholding them. Alternatively, states’ rights might be justified by a natural duty of justice to uphold and not to obstruct institutions implementing publichealth policies. I indicate some reasons for preferring the latter justification. I further argue that the assignment of some rights to states via publichealth-based justification is undermined on several counts. Domestic political institutions cannot effectively perform some of their functions in protecting publichealth. Furthermore, transborder publichealth threats pose collective action problems at the global level. Finally, concerns about human rights work against the assignment of some rights to states. I conclude by arguing that these concerns call for global coordination, and that some rights claimed by states ought instead to be assigned to global institutions. CiteULike Connotea Del.icio.us What's this? (shrink)
Comprehensive Biomedical Research Centre and Centre for Philosophy, Justice and Health, UCL, First Floor, Charles Bell House, 67–73 Riding House Street, London W1W 7EJ, UK. Tel.: +44 (0)20 7679 9417; Fax: +44 (0)20 7679 9426; Email: james-gs.wilson{at}ucl.ac.uk ' + u + '@' + d + ' '//--> . Abstract This paper aims to shed some light on the difficulties we face in constructing a generally acceptable normative framework for thinking about publichealth. It argues that there are (...) three factors that combine to make theorising about publichealth difficult, and which when taken together defeat simplistic top-down and bottom-up approaches to the design of publichealth policies. The first factor is the problem of complex systems, namely that the distribution of health both affects and is affected by the distribution of other goods. The second is the difficulty of defining the goals of publichealth: we still need to get clear about what we should mean by health in this context, and what the goals of publichealth should be. The third is that we stand in need of an account of how important health is relative to the importance of other goods that a just society should be trying to secure for its citizens. The paper argues that these problems should lead us to abandon the search for a ‘one-size fits all’ normative framework for thinking about publichealth. Rather, different approaches will be appropriate at different levels of abstraction. CiteULike Connotea Del.icio.us What's this? (shrink)
While promoting population health has been the classic goal of publichealth 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 publichealth, 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 publichealth 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 publichealth policies. A number of practical implications regarding, e.g., the importance of respecting autonomy and the allocation of publichealth resources are noted, as are a battery of questions for further research. (shrink)
This article aims to contribute to the application of ethical frameworks to publichealth policy. In particular, the article considers the use of the Nuffield Council on Bioethics stewardship model, as an applied framework for the evaluation of evidence within publichealth policymaking. The ‘Stewardship framework’ was applied to a policy proposal to restrict marketing of food and beverages to children. Reflections on applying the stewardship model as a framework are provided. The article concludes that the (...) questions used to apply the stewardship model usefully introduced ethical considerations into the evidence review. However, the real value will likely come from the type of policy process within which the framework is used, identifying competing value positions and capturing local value requirements. (shrink)
Publichealth communications often attempt to persuade their audience to adopt a particular belief or pursue a particular course of action. To a large extent, the ethical defensibility of persuasion appears to be assumed by publichealth practitioners; however, a handful of academic treatments have called into question the ethical defensibility of persuasive risk- and health communication. In addition, the widespread use of persuasive tactics in publichealth communications warrants a close look at (...) their ethical status, irrespective of previous critiques. In this article, we review some ethical objections previously advanced against the use of persuasion in publichealth communications, and also consider some novel but potentially relevant objections. We conclude that persuasion is ethically problematic in some circumstances and attempt to clarify what these circumstances are. However, whereas persuasion may be ethically problematic in some circumstances, it need not be viewed as intrinsically problematic. (shrink)
Conventional and well-established guidelines for the ethical conduct of clinical research are necessary but not sufficient for addressing research dilemmas related to publichealth research. There is a particular need for a publichealth ethics framework when, in the face of an epidemic, research is urgently needed to promote the common good. While there is limited experience in the use of a publichealth ethics framework, the value and potential of such an approach is (...) increasingly being appreciated. Here we use two examples of adolescent women as potential candidates for participation in microbicide trials to illustrate how ethical decisions for publichealth research can be enhanced by drawing on both traditional research ethics guidance, and the emerging framework for publichealth ethics. (shrink)
WHO suggests mental ill health in terms of depression to be the highest ranking disease problem in the developed world in 2020–2030 and claims a publichealth approach to be the most appropriate response. But some argue that the alarming reports on mental ill health have their ground in the methods of inquiry themselves and refer to medicalization as an important issue. The aim of this article is to explore and illuminate the issue of what is (...) meant by mental health and mental ill health and what it means that mental ill health is a major publichealth problem. Basically, two understandings and aspects of publichealth exist: a ‘reductionist’ and a ‘holistic’ with connections to different theories of health. These diverging understandings may lead to quite different publichealth responses, and they may have different consequences with regard to medicalization. It is concluded that we need more clearly elaborated ways to think about publichealth so that the increased attention to mental ill health as a publichealth problem does not in itself lead to medicalization in terms of just medical treatment. Otherwise, we risk losing the importance of publichealth as an overarching social and political instrument. (shrink)
This comment on the case presented in ‘Cholera and Nothing More’ argues that the physicians at this public-health centre did not have an ordinary clinician's obligations to promote the health of the people who came to them for care, as they were instead set up to serve a laudable and urgent public-health goal, namely, controlling a cholera outbreak. It argues that, nonetheless, these physicians did have some limited moral duties to care for other diseases they (...) encountered—some ancillary-care duties—arising from their voluntarily entering into a kind of intimate relationship with the patients they took in, one in which those patients effectively waive certain rights to bodily and medical privacy. (shrink)
Machine generated contents note: Preface; Introduction Angus Dawson; Part I. Concepts: 1. Resetting the parameters: publichealth as the foundation for publichealth ethics Angus Dawson; 2. Health, disease and the goal of publichealth Bengt Brülde; 3. Selective reproduction, eugenics and publichealth Stephen Wilkinson; 4. Risk and precaution Stephen John; Part II. Issues: 5. Smoking, health and ethics Richard Ashcroft; 6. Infectious disease control Marcel Verweij; 7. Population screening (...) Ainsley Newson; 8. Vaccination ethics Angus Dawson; 9. Environment, ethics and publichealth: the climate change dilemma Anthony Kessel and Carolyn Stephens; 10. Publichealth research ethics: is non-exploitation the new principle for population-based research ethics? John McMillan; 11. Equity and population health: toward a broader bioethics agenda Norman Daniels; 12. Health inequities James Wilson; Index. (shrink)
In this response to Jonny Anomaly’s ‘Is Obesity a PublicHealth Problem?’ I argue, contra the author that publichealth actually increases individuals’ abilities to choose actions that further their health goals, specifically in the case of obesity. The intractability of obesity as an individual medical problem combined with the health benefits of modest (5–10 per cent of body weight) weight loss suggest that publichealth measures helping people make small changes in (...) eating habits improve population health. I argue that such measures are available to publichealth via behavioral economic research and policy proposals from libertarian paternalists. I respond to author’s claim that obesity does not constitute a publichealth problem because: (i) it is not an epidemic and (ii) obesity reduction is not a public good. I argue that epidemic status is not required for classification as a publichealth problem, but that obesity does have the status of an epidemic. I also point out flaws in author’s reasoning about obesity, publichealth and social costs. I conclude by suggesting that publichealth, in partnership with stakeholders and other areas of government, is poised to help create conditions for modest weight loss and increased population health overall. (shrink)
The success of the health care system depends on the accuracy, correctness and trustworthiness of the information, and the privacy rights of individuals to control the disclosure of personal information. A national policy on health informational privacy should be guided by ethical principles that respect individual autonomy while recognizing the important collective interests in the use of health information. At present there are no adequate laws or constitutional principles to help guide a rational privacy policy. The (...)laws are scattered and fragmented across the states. Constitutional law is highly general, without important specific safeguards. Finally, a case study is provided showing the important trade-offs that exist between publichealth and privacy. For a model publichealth law, see www.critpath.org/msphpa/privacy. (shrink)
Vaccination programmes against infectious diseases aim to protect individuals from serious illness but also offer collective protection once a sufficient number of people have been immunized. This so-called ‘herd immunity’ is important for individuals who, for health reasons, cannot be immunized or who respond less well to vaccines. For these individuals, it is pivotal that others establish group protection. However, herd immunity can be compromised when people deliberately decide not to be immunized and benefit from the herd’s protection. These (...) agents are often referred to as free riders: their omissions are deemed to be unfair to those who do contribute to the collective’s health. This article addresses the unfairness of such ‘free riding’. An argument by Garett Cullity is examined, which asserts that the unfairness of moral free riding lies neither in one’s intentions, nor in one’s reluctance to embrace a public good. This argument offers a strong basis for justifiably arguing that free riding is unfair. However, it is then argued that other considerations also need to be taken into account before simply holding free riding against non-compliers. (shrink)
The Patient Protection and Affordable Care Act (ACA) sets in motion a wide range of programs that substantially affected the health system in the United States and signify a moderate but important regulatory shift in the role of the federal government in publichealth. This article briefly addresses two interesting policy paradoxes about the ACA. First, while the legislation primarily addresses health care financing and insurance and establishes only a few initiatives directly targeting public (...) class='Hi'>health, the ACA nevertheless has the potential to produce extensive publichealth benefits across the United States population by improving access to health care and services and reducing cost. Essentially, the ACA does not take the explicit form of a publichealth law but instead strives to advance publichealth indirectly through its effects. Second, while the ACA does not establish a right to health — or even a right to health insurance — in the United States, it does set in motion a number of significant structural and normative changes to United States law that comport with the attainment of the right to health. Most significantly, key provisions of the bill are designed to improve availability, accessibility, acceptability, and quality of conditions necessary for health, and to prompt the government to respect, protect, and fulfill these conditions. These developments mean that, to a degree, the United States essentially has undertaken the same types of legal and policy steps that a country would be required to take to uphold the right to health without actually recognizing the right to health in any formal or legally binding way.Despite these dual paradoxes and the upside potential for publichealth improvements resulting from the ACA, the publichealth impact of the law remains uncertain and will be decided by numerous subsequent regulatory and implementation decisions. The ACA authorizes multiple federal agencies to engage in rulemaking, a process that will largely dictate the systemic and health impacts that will become its legacy. This reality opens up ample opportunity to bolster publichealth aspects and interpretations of the law, and to simultaneously augment the corresponding components of the right to health. (shrink)
The Patient Protection and Affordable Care Act created the nation's first comprehensive comparative effectiveness research (CER) program. According to some optimistic accounts, CER will revolutionize clinical practice and transform the health care delivery system. But what about publichealth? There are reasons for concern that it could end up left behind in the new era of comparative effectiveness. This article analyzes the considerable promise and serious limitations of applying CER to publichealth. It also highlights (...) important issues that will likely emerge for publichealth law and policy as the health care system transitions to greater reliance on CER. (shrink)
Even when turning its attention to publichealth topics such as preventive care and workplace wellness, the Affordable Care Act law embodies a highly individualistic paradigm of health. The provisions of the law implicitly assign the primary responsibility for prevention to individuals, who should be urged to make more responsible and healthier choices about what they consume and how they live. Relatively little in the law reflects the “population perspective” set forth in publichealth scholarship (...) that focuses on environmental and social determinants of health. This article explores the cultural and economic factors that led Congress to embrace a highly individualist conception of publichealth, and it suggests how publichealth advocates and legal scholars might seek to reframe the public discourse surrounding preventive health issues. (shrink)
We are unlikely to stop seeking pleasure, as this would prejudice our health and well-being. Yet many psychoactive substances providing pleasure are outlawed as illicit recreational drugs, despite the fact that only some of them are addictive to some people. Efforts to redress their prohibition, or to reform legislation so that penalties are proportionate to harm have largely failed. Yet, if choices over seeking pleasure are ethical insofar as they avoid harm to oneself or others, publichealth (...) strategies should foster ethical choice by moving beyond current risk management practices embodied in the harm reduction movement. The neuroscience of pleasure has much to offer neuroethics and publichealth strategies. Distinguishing between ‘wanting’ and ‘liking’ fosters new understandings of addiction. These hold promise for directing the search for pharmacotherapies which prevent addiction and relapse or disrupt associated neuromechanisms. They could inform new research into creating lawful psychoactive substances which give us pleasure without provoking addiction. As the health and well being of human and other animals rests upon the experience of pleasure, this would be an ethical objective within publichealth strategy. Were ethical and neurobiological obstacles to ending addiction to be overcome, problems associated with excessive consumption, the lure of unlawful psychoactive substances and the paucity of lawful means to achieve pleasurable altered states would remain. Non-addictive designer drugs, which reliably provided lawful access to pleasures and altered states, would ameliorate these publichealth concerns insofar as they fostered citizens’ informed, ethical choices according to a neurobiological taxonomy of pleasures. (shrink)
Television advertisements depicting the use of electronic cigarettes have recently exposed minors to images of smoking behaviors. While these advertisements are currently legal, existing laws should be interpreted or expanded to ban the commercial depiction of smoking behaviors with any product that resembles a cigarette to shield minors from potentially influential advertising.
Publichealth is an important and fast-developing area of ethical discussion. In this volume a range of issues in publichealth ethics are explored using the resources of moral theory, political philosophy, philosophy of science, applied ethics, law, and economics. The twelve original papers presented consider numerous ethical issues arise within publichealth ethics. To what extent can the public good or the public interest justify state interventions that impose limits upon the (...) freedom of individuals? What role should the law play in regulating risks? Should governments actively aim to change our preferences about such things as food, smoking or physical exercise? What are public goods, and what role (if any) do they play in publichealth? To what extent do individuals have moral obligations to contribute to protecting the community or the public good? Where is it appropriate to concentrate upon prevention rather than cure? Given the fact that we cannot be protected from all harm, what sorts of harm provide a justification for publichealth action? What limits do we wish to place upon publichealth activities? How do we ensure that the interests of individuals are not set aside or forgotten in the pursuit of population benefits? -/- An excellent line-up of authors from North America, Europe, and the UK tackle these questions. (shrink)
The paper addresses the question of how different types of evidence ought to inform publichealth policy. By analysing case studies on obesity, the paper draws lessons about the different roles that different types of evidence play in setting up publichealth policies. More specifically, it is argued that evidence of difference-making supports considerations about ‘what works for whom in what circumstances’, and that evidence of mechanisms provides information about the ‘causal pathways’ to intervene upon.
Khalafzai, Rida Usman In this era, health has been redefined. The emphasis has shifted from the individual-focussed bio-medical model to a preventative model of collective health. This model of publichealth often challenges the concept of individual autonomy, the basis of human rights, in the name of the greater good. This article explores the relationship between publichealth and human rights, and the need for a publichealth ethic based on the principles (...) of human rights. (shrink)
