While Powers and Faden do not consider possible anti-paternalism objections to their view, there are two variants of this objection that a social justice perspective is susceptible to. It is worth exploring which responses to such objections may be less promising than others. It is argued that for most public health measures targeting the disadvantaged, theorists and practitioners taking a social justice perspective should bite the paternalist bullet. Insofar as the government has the ability to reduce mortality and morbidity within (...) the population in a way that is fair and in everyone’s interests, then the use of paternalistic means or resultant paternalistic effects should be thought to be the lesser evil. (shrink)

There are several strategies to promote health in individuals and populations. Two general approaches to health promotion are behavior change and empowerment. The aim of this article is to present those two kinds of strategies, and show that the behavior-change approach has some moral problems, problems that the empowerment approach (on the whole) is better at handling. Two distinct ‘ideal types’ of these practices are presented and scrutinized. Behavior change interventions use various kinds of theories to target people’s behavior, which (...) they do through information, persuasion, coercion and manipulation. Empowerment is a collaborative method where those ‘facilitated’ participate in the change process. Some ethical problems with the behavior-change model are that it does not sufficiently respect the right to autonomy of the individuals involved and risks reducing their ability for autonomy, and that it risks increasing health inequalities. Empowerment, on the other hand, respects the participant’s right to autonomy, tends to increase the ability for autonomy, as well as increasing other coping skills, and is likely to reduce inequalities. A drawback with this approach is that it often takes longer to realize. (shrink)

This is lightly edited and referenced version of a presentation given at the 20th International Philosophy of Nursing conference in Quebec on 23rd August 2016. Philosophical texts are not given the same prominence in nurse education as their more valued younger sibling, primary research evidence, but they can influence practice through guidelines, codes and espoused values. John Stuart Mill’s harm principle, found in On Liberty, is not a universal law, and only a thoroughgoing libertarian would defend it as such, though (...) it, or its remnants, can be seen can be seen in policy documents. But its influence is weakening. Smoking bans in enclosed spaces were initially justified with other‐regarding considerations, but judgements from unsuccessful legal challenges from patients in UK psychiatric hospitals rely on preventing harm to the smoker, even when smoking outside, which does not harm others. In the wake of legislation, no‐smoking policies enacted by hospitals are becoming more aggressive, banning smoking both inside and outside, and extending the use of power gained through employment to prevent nurses assisting patients enjoy a lawful habit. Mill’s dictum has been subverted, and this speaks to the fundamental purpose of nursing. Should nurses collude and willingly exert their power for their version of the good of the patient? Or should they instead reaffirm values that support and facilitate life choices made by autonomous people? The paper supports the latter option, and this has wider application for nursing which can be illuminated, if not settled, by revisiting Mill and his famous dictum. (shrink)

The current scandal surrounds the global breast implant scare of silicone implants made by France's Poly Implant Prothese (PIP) Company. An ensuing review recognized that efforts in investigating the distress caused to so many women were hampered by a lack of reliable and comprehensive information about all the adverse incidents relating to PIP breast implants, as well as uncertainty about comparative data on similar products. One of the recommendations following the review was the investigation of the potential for re-establishing a (...) breast implant registry, which could facilitate the availability of adverse incident reporting in cases such as these. The insistence of compulsory inclusion in such registries would override the debate on informed consent in epidemiological studies and public health. The ethics of clinical research with its focus on individual consent is difficult to reconcile with the ethical requirements of research at a population level as in the case of registries. (shrink)

I warmly thank Richard Ashcroft, Luc Bovens, Gerald Dworkin, Brynn Welch, and Alan Wertheimer for their insightful comments on my article. As I do not have the space to discuss all the questions they raise, I will focus on four concerns that run through my commentators’ responses...

In recent years, ‘nudge’ theory has gained increasing attention for the design of population-wide health interventions. The concept of nudge puts a label on efficacious influences that preserve freedom of choice without engaging the influencees’ deliberative capacities. Given disagreements over what it takes genuinely to preserve freedom of choice, the question is whether health influences relying on automatic cognitive processes may preserve freedom of choice in a sufficiently robust sense to be serviceable for the moral evaluation of actions and policies. (...) In this article, I offer an argument to this effect, explicating preservation of freedom of choice in terms of choice-set preservation and noncontrol. I also briefly explore the healthcare contexts in which nudges may have priority over more controlling influences. (shrink)

Articles by Lyn Horn and Alison Thompson highlight several points crucial to understanding how our theory figures in wider debates about social justice as well as the particular relevance of our theory for assessing the overall practice of public health (Horn, 2013; Thompson, 2013). We begin with these two articles, first to respond to and concur with many of their central points, and second to set the stage for dealing more efficiently with some points raised in the other articles.

The aim of this article is twofold. First is to demonstrate that most values that underpin public health policy are a source of reasonable disagreement amongst citizens to whom said policy applies....

Medical and non-medical experts increasingly argue that individuals, whether they are diagnosed with a specific chronic disease or condition or not (and whether they are judged at minimal risk of these consequences or not), have an obligation to make ‘healthy’ food choices. We argue that this obligation is neither scientifically nor ethically justified at the level of the individual. Our intent in the article is not simply to argue against moralization of the value of prudential uses of food for nutritional (...) health, but to situate nutritional advocacy in the context of Western liberal democracy that values free choice. We have two objectives: (i) to untangle and examine the substance of discourses on ‘healthy’ food choice that simplify nutrition science and place a moral obligation on individuals and (ii) to establish a more comprehensive view of the relationship among food, ethics and health. Although critical of certain features of the liberal political and moral tradition, we argue that John Stuart Mill’s notion of experiments in living provides fertile ground for an improved ethical understanding of individual obligation and of the interconnections among food, health and well-being. (shrink)

Volume 20, Issue 7, July 2020, Page 169-172.

Widespread obesity poses a serious challenge to health outcomes in the developed world and is a growing problem in the developing world. There has been a raft of proposals to combat the challenge of obesity, including restrictions on the nature of food advertising, the content of prepared meals, and the size of sodas; taxes on saturated fat and on calories; and mandated “healthy-options” on restaurant menus. Many of these interventions seem to have a greater impact on rates of obesity than (...) does simply providing information about health risks and healthier lifestyles. The more interventionist policy options have, however, been implemented only slowly, in large part because of criticisms that they are unjustified infringements on the liberty of consumers. Food industry groups, free-market think tanks, and the popular press regard measures that incentivize or penalize particular food and lifestyle choices as unjustifiable state regulation of purely self-regarding behavior. To counteract the liberty-oriented position, those who favor a more interventionist role for the state have recently argued for labeling obesity as a public health emergency. By labeling obesity as a public health emergency, policy-makers could override concerns about individual liberty in order to pursue more interventionist policies designed to guide consumer choices toward healthier lifestyles. In this paper, we argue that, contrary to initial appearances, obesity possesses some of the morally relevant features of public health emergencies, though we do not argue that it actually constitutes one. (shrink)

A wide range of non-pharmaceutical interventions (NPIs) have been introduced to stop or slow down the COVID-19 pandemic. Examples include school closures, environmental cleaning and disinfection, mask mandates, restrictions on freedom of assembly and lockdowns. These NPIs depend on coercion for their effectiveness, either directly or indirectly. A widely held view is that coercive policies need to be publicly justified—justified to each citizen—to be legitimate. Standardly, this is thought to entail that there is a scientific consensus on the factual propositions (...) that are used to support the policies. In this paper, we argue that such a consensus has been lacking on the factual propositions justifying most NPIs. Consequently, they would on the standard view be illegitimate. This is regrettable since there are good reasons for granting the state the legitimate authority to enact NPIs under conditions of uncertainty. The upshot of our argument is that it is impossible to have both the standard interpretation of the permissibility of empirical claims in public justification and an effective pandemic response. We provide an alternative view that allows the state sufficient room for action while precluding the possibility of it acting without empirical support. (shrink)

Public health aims to provide universal safety and progressive opportunities to populations to realise their highest level of health through prevention of disease, its progression or transmission. Screening asymptomatic individuals to detect early unapparent conditions is an important public health intervention strategy. It may be designed to be compulsory or voluntary depending on the epidemiological characteristics of the disease. Integrated screening, including for both syphilis and cancer of the cervix, is a core component of the national reproductive health program in (...) Kenya. Screening for syphilis is compulsory while it is voluntary for cervical cancer. Participants’ perspectives of either form of screening approach provide the necessary contextual information that clarifies mundane community concerns. (shrink)

Given the evolution of the public health (PH) and the changes from the phenomenon of globalization, this area has encountered new ethical challenges. In order to find a coherent approach to address ethical issues in PH policy, this study aimed to identify the evolution of public health ethics (PHE) frameworks and the main moral values and norms in PH practice and policy. According to the research questions, a systematic search of the literature, in English, with no time limit was performed (...) using the main keywords in databases Web of Science (ISI) and PubMed. Finally, the full text of 56 papers was analyzed. Most of the frameworks have common underpinning assumptions and beliefs, and the need to balance PH moral obligation to prevent harm and health promotion with respect for individual autonomy has been specified. As such, a clear shift from liberal values in biomedical ethics is seen toward the community’s collective values in PHE. The main moral norms in PH practice and policy included protecting the population against harm and improving PH benefits, utility and evidenced-based effectiveness, distributive justice and fairness, respect for all, privacy and confidentiality, solidarity, social responsibility, community empowerment and participation, transparency, accountability and trust. Systematic review of PHE frameworks indicates utilization of the aforementioned moral norms through an practical framework as an ethical guide for action in the PH policy. The validity of this process requires a systematic approach including procedural conditions. (shrink)