The intervention stairway emerges from recognising the complexity inherent in public health issues. While the original intervention ladder is a valuable tool, it risks ignoring this complexity, narrowing our focus to individual-level interventions at the expense of systemic considerations. Some have interpreted this critique as claiming the ladder entirely precludes consideration of systemic factors.1 This is not the case. Instead, the claim is that the ladder obscures these factors, making them more challenging to recognise and incorporate into policy. This critique (...) has generated several responses. Smith and Gauthier argue that the ladder will not obscure systemic considerations as it is primarily a tool for policy evaluation, not policy creation.1 Moreover, they suggest that even if used for policy creation, the ladder will likely generate systemic interventions as these are often less intrusive. By contrast, Dawson has objected to the stairways’ focus on intrusiveness, supposedly at the expense of other values, saying, ‘the only justification for a tool such as the intervention ladder is if liberty is, implausibly, given some privileged status over other values’.2 These critiques warrant careful consideration but ultimately misunderstand the purpose of both the original ladder and the proposed stairway. Neither tool is meant to privilege liberty or be used in isolation. Rather, they are tools for weighing considerations of intrusiveness and proportionality designed to be applied within …. (shrink)

The Nuffield Council on Bioethics introduced an ‘intervention ladder’ to guide policymakers on public health interventions. 1 The ladder’s vertical structure represents an ordering of interventions, from least to most intrusive. In his article, Paetkau acknowledges that this ladder is ‘a useful tool’ (p. 1) for evaluating public health interventions. 2 However, he objects that its focus on individual behaviour is too narrow and obscures ‘interventions that operate on the level of systems rather than individuals’ (p. 2). To be sure, (...) some of the interventions on the original ladder do involve what might ordinarily be seen as ‘system’ or environmental changes. For instance, we might encourage active transport by building dedicated cycle lanes. However, these measures still have their intended effects through altering individual choices. What Paetkau means by a ‘systemic intervention’ is specifically one that improves public health _without_ changing individual behaviour change (pp. 2–3). For... (shrink)

Neuropsychiatric disorders such as drug addiction, depression and schizophrenia are often centrally implicated in public health challenges. These conditions impact the individuals affected and have widespread implications, contributing to related crises such as opioid epidemic, rising suicide rates and homelessness. Despite their influence, public health interventions frequently emphasise individual responsibility, overlooking the complex interplay of neurobiological and systemic factors that underpin these disorders. Current public health frameworks, such as the Nuffield Council on Bioethics’ intervention ladder, prioritise efforts that encourage individual (...) behaviour change. Paetkau critiques this emphasis on individual responsibility, emphasising the need to consider more systemic factors, such as social determinants of health, as targets of necessary intervention.1 We aim to reinforce Paetkau’s critique of the intervention ladder by introducing three neuropsychiatric case studies, each highlighting the limitations of an individual-based framework in addressing psychopathology-involved public health issues. We argue that conditions like addiction, depression and serious mental illness undermine the emphasis on individual responsibility in public health and policy interventions. To this end, neuroscience demonstrates that effective public health interventions necessitate a shift from the long-standing emphasis on individual responsibility towards more comprehensive, systems-level interventions. Opioid overdose deaths in the USA have sextupled since 1999, with over 100,000 deaths in 2023 alone.2 The opioid crisis has since remained one of the most pressing public …. (shrink)

In his feature article, Tyler Paetkau1 argues that the Nuffield Council on Bioethics’ (NCOB) infamous intervention ladder2 fails to acknowledge systemic influences towards poor health outcomes and instead places the blame on individuals. The ladder of interventions to change individual health behaviours runs from less intrusive to more intrusive and pays less attention to possible regulatory mechanisms for big businesses that would often avoid such intrusion on individuals and the punitive implications of that intrusion. Paetkau cites smoking bans and food (...) labelling as examples of various levels of public health measures intruding on individual freedoms. According to him, instead of preventing people from smoking in public spaces or trying to influence their food purchase decisions, we should instead address the social determinants of health through systemic interventions, by which he means ‘interventions that operate on the level of systems rather than individuals and do not target or require individual behaviour change’1 (p. 2). The argument, however, might be questioned. At points in the article, Paetkau proposes that his new, broadened ‘stairway’ set of public health interventions ‘highlights the intimate connection between systemic interventions and individual outcomes’1 (p. 5). However, in some places, …. (shrink)

Tyler Paetkau, in his paper ‘Ladders and Stairs: how the intervention ladder focuses blame on individuals and obscures systemic failings and interventions’, adds to the growing body of academic literature raising questions about the appropriateness and usefulness of the Nuffield Council on Bioethics (NCB)’s intervention ladder (2007) as a tool for policymakers.1 2 Paetkau is critical of the intervention ladder because he holds that it focuses on individual choice and personal responsibility and pays insufficient attention to ‘systemic interventions’. He suggests (...) substituting the new metaphor of an ‘intervention stairway’ for that of the intervention ladder. I argue that his diagnosis of the problems does not go far enough and that his suggested alternative metaphor is more confusing than helpful. Paetkau’s critical analysis of the intervention ladder makes some good points. It is true that this metaphor assumes a narrow range of policy options, with a focus on changing individual behaviour, and a consequent emphasis on personal responsibility. This is the flip-side of the NCB’s focus on liberty as always being a positive value and restriction seen as intrinsically wrong. Paetkau points out that this means that much routine public health action directed at changing the more structural features that impact on health is missing from the story. I set this …. (shrink)