Michael Bloomberg's three terms in New York City's mayoral office are coming to a close. His model of governance for public health influenced cities and governments around the world. What should we make of that model? This essay introduces a symposium in which ethicists Sarah Conly, Roger Brownsword and Alex Rajczi discuss that legacy.

There is an underappreciated disconnect between the ultimate values that lie at the heart of contemporary theories of distributive justice, and the practice of state institutions. State institutions deliver “intermediate goods” – goods such as health-care, education, housing, transportation, and the like – that are instrumental to a society being distributively just, but that do not in an of themselves constitute criteria of justice. Researchers who have emphasized the “social determinants of health” provide an insight that, when generalized, point us (...) in a direction that theorists of distributive justice should follow, that of attending not just to the instrinsic value of intermediate goods, but also to their causal contributions to realizing the values that theories of distributive justice make central. “Platforms”, which represent principle-driven attempts at designing compossible policies that attend both to the causal and to the intrinsic value of intermediate goods, should be given more importance within theories of distributive justice if such theories are to be policy-relevant, for they connect the ultimate values of these theories to the practices of state institutions. (shrink)

Smoking is disproportionately common among the disadvantaged, both within many countries and globally; the burden associated with smoking is, therefore, borne to a great extent by the disadvantaged. In this paper, I argue that this should be regarded as a problem of social justice. Even though smokers do, in a sense, ‘choose’ to smoke, the extent to which these choices can legitimise the resulting inequalities is limited by the unequal circumstances in which they are made. An analysis of the empirical (...) literature reveals a variety of factors—such as targeted advertising, unequal dissemination of information about the health risks of smoking and inequalities in smoking norms—that make the disadvantaged more likely to become smokers and less likely to quit successfully. The paper then considers a range of common tobacco control policies from the perspective of social justice. The social justice perspective developed here poses a challenge for policy-makers: on the one hand, social justice concerns strengthen the case for tobacco control policies because such policies disproportionately benefit the health of the disadvantaged. At the same time, however, we must be particularly sensitive to any harms associated with such policies because such burdens, too, will fall largely on the disadvantaged. (shrink)

This paper defends a distinctly liberal approach to public health 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 public health'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 public health. 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)

In this article, we address the relevance of J.S. Mill’s political philosophy for a framework of public health 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 public health ethics that would modify how the balancing of some liberty and public health 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 public health objectives without any presumption in favor of liberty. (shrink)

University of Utrecht, Department of Philosophy, Heidelberglaan 6, 3584 CS Utrecht, The Netherlands. Tel.: +31 30 253 28 74, Email: Thomas.Nys{at}phil.uu.nl ' + u + '@' + d + ' '//-->Measures in public health care 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: Measures in PHC (...) are aimed to protect, restore or promote ‘deep autonomy’, Measures in PHC are directed at the public and, as such, they do show respect for autonomy, and 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)

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 public health 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 public health ethics. (shrink)

In his most recent book, Philip Pettit presents and defends a “republican” political philosophy that stems from a tradition that includes Cicero, Machiavelli, James Harrington, Locke, Montesquieu, Rousseau, and Madison. The book provides an interpretation of what is distinctive about republicanism—namely, Pettit claims, its notion of freedom as nondomination. He sketches the history of this notion, and he argues that it entails a unique justification of certain political arrangements and the virtues of citizenship that would make those arrangements possible. Of (...) historical and philosophical interest, he stresses, is the fundamental contrast between freedom as nondomination and slavery. Joseph Priestly, for instance, invoked this contrast in defending the cause of the American Revolution, and in 1769 declared, incredibly, that if the parliament of Great Britain continued to tax the American colonies, “the colonists will be reduced to a state of as complete servitude, as any people of which there is an account in history”. Those opposed to American independence, among them Jeremy Bentham, relied instead on a Hobbesian notion of freedom as noninterference, using it to argue that the colonists were no more interfered with by the British government than were citizens of Britain. Drawing out this contrast, Pettit aims to establish that a republican view of freedom better supports the institutions of a constitutional democracy than does liberalism. His account of the distinguishing characteristics and strengths of republicanism is, however, only partially successful. Neither his case that a republican notion of freedom provides for a more solid defense of democratic institutions and constitutional protections than is available within liberalism, nor his argument that republicanism can better address “private” injustices, is convincing. (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 public health 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 public health 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 public health ethics because it contains within itself the basis for its own moral limitation. CiteULike Connotea Del.icio.us What's this? (shrink)

In this essay I argue that the same considerations that justify the strong commitment to anti-paternalism that has been affirmed in bioethics over the past half century, also calls for anti-paternalistic public health policies. First, I frame the puzzle—why are citizens morally entitled to make unhealthy and medically inadvisable decisions as patients but not as consumers? I then briefly sketch the reasons why bioethicists typically reject paternalism. Next, I argue that those same reasons tell against paternalism in public health ethics (...) as well. Patients do not waive their rights to make medically inadvisable decisions when they leave their physician’s care. James Wilson disagrees. After I sketch Wilson’s arguments for paternalism in public health policy, I then argue, contra Wilson, that public health paternalism is wrong for the same reason that medical paternalism is wrong, and that the prevalence of paternalism in public policy does not mean that paternalism is morally permissible. I discuss the state’s authority to enforce paternalistic policies and I sketch an anti-paternalist vision for health policymakers. To close, I consider several objections. (shrink)

Fairchild, Center for the History and Ethics of Public Health in the Department of Sociomedical Sciences at Columbia University's Mailman School of Public Health Abstract Surveillance is a cornerstone of public health. It permits us to recognize disease outbreaks, to track the incidence and prevalence of threats to public health, and to monitor the effectiveness of our interventions. But surveillance also challenges our understandings of the significance and role of privacy in a liberal democracy. In this paper we trace the (...) century-long history of public health surveillance in the United States situating that history in the context of the broad social, political, and ideological forces that have shaped our conceptions of privacy. Although we focus here on the United States, the debates over privacy that unfolded in the 1960s were repeated in many European nations. The themes we explore here, then, provide a framework for examining the relationship between privacy and public health in other contexts. CiteULike Connotea Del.icio.us What's this? (shrink)

Jeremy Waldron is one of the world's leading legal and political philosophers. This collection brings together thirteen of his most recent essays which, in the course of working the book up for publication, the author has revisited and thoroughly revised. He addresses central issues within the liberal tradition, focusing on the law and its role in a pluralistic state which experiences deep disagreements about values and rights, and about the role of the state itself.

Author Jeremy Waldron has thoroughly revised thirteen of his most recent essays in order to offer a comprehensive critique of the idea of the judicial review of legislation. He argues that a belief in rights is not the same as a commitment to a Bill of Rights. This book presents legislation by a representative assembly as a form of law making which is especially apt for a society whose members disagree with one another about fundamental issues of principle.

According to republican theory, we are free persons to the extent that we are protected and secured in the same fundamental choices, on the same public basis, as one another. But there is no public protection or security without a coercive state. Does this mean that any freedom we enjoy is a superficial good that presupposes a deeper, political form of subjection? Philip Pettit addresses this crucial question in On the People's Terms. He argues that state coercion will not involve (...) individual subjection or domination insofar as we enjoy an equally shared form of control over those in power. This claim may seem utopian but it is supported by a realistic model of the institutions that might establish such democratic control. Beginning with a fresh articulation of republican ideas, Pettit develops a highly original account of the rationale of democracy, breathing new life into democratic theory. (shrink)

This study builds on the work of contemporary civic republicans, supplying a detailed analysis of the concept of domination absent in the familiar accounts of political freedom as non-domination.

Informed consent is a central topic in contemporary biomedical ethics. Yet attempts to set defensible and feasible standards for consenting have led to persistent difficulties. In Rethinking Informed Consent in Bioethics Neil Manson and Onora O'Neill set debates about informed consent in medicine and research in a fresh light. They show why informed consent cannot be fully specific or fully explicit, and why more specific consent is not always ethically better. They argue that consent needs distinctive communicative transactions, by which (...) other obligations, prohibitions, and rights can be waived or set aside in controlled and specific ways. Their book offers a coherent, wide-ranging and practical account of the role of consent in biomedicine which will be valuable to readers working in a range of areas in bioethics, medicine and law. (shrink)

This is the first full-length presentation of a republican alternative to the liberal and communitarian theories that have dominated political philosophy in recent years. The latest addition to the acclaimed Oxford Political Theory series, Pettit's eloquent and compelling account opens with an examination of the traditional republican conception of freedom as non-domination, contrasting this with established negative and positive views of liberty. The first part of the book traces the rise and decline of this conception, displays its many attractions, and (...) makes a case for why it should still be regarded as a central political ideal. The second part of the book looks at what the implementation of the ideal would imply for substantive policy-making, constitutional and democratic design, regulatory control and the relation between state and civil society. Prominent in this account is a novel concept of democracy, under which government is exposed to systematic contestation, and a vision of relations between state and society founded upon civility and trust. Pettit's powerful and insightful new work offers not only a unified, theoretical overview of the many strands of republican ideas, but also a new and sophisticated perspective on studies in related fields including the history of ideas, jurisprudence, and criminology. (shrink)