How far should we go in protecting and promoting public health? Can we force people to give up unhealthy habits and make healthier choices, or does everyone have the right to decide their own lifestyle? Should we stop treating smokers who refuse to give up smoking? Should we put a tax on fatty foods and ban vending machines in schools to address the obesity epidemic? Should parents be required to have their children vaccinated? Are some of our screening programmes unethical (...) Downs syndrome screening, for example or should we be screening people for more conditions, such as Huntington disease? Such questions are at the heart of public health ethics. Holland shows that to understand and debate these issues requires philosophy: moral philosophies, such as utilitarianism and deontology, as well as political philosophies such as liberalism and communitarianism. And philosophy informs other aspects of public health, such as epidemiology and health promotion. The aim of this book is to provide a lively, accessible and philosophically informed introduction to such issues. It is an ideal textbook for students taking courses in public health ethics. And since this book develops systematic discussions of issues in public health ethics, there is also much here to engage and challenge the more advanced reader. (shrink)

In bioethics, the predominant categorization of various types of influence has been a tripartite classification of rational persuasion (meaning influence by reason and argument), coercion (meaning influence by irresistible threats—or on a few accounts, offers), and manipulation (meaning everything in between). The standard ethical analysis in bioethics has been that rational persuasion is always permissible, and coercion is almost always impermissible save a few cases such as imminent threat to self or others. However, many forms of influence fall into the (...) broad middle terrain—and this terrain is in desperate need of conceptual refining and ethical analysis in light of recent interest in using principles from behavioral science to influence health decisions and behaviors. This paper aims to address the neglected space between rational persuasion and coercion in bioethics. First, I argue for conceptual revisions that include removing the “manipulation” label and relabeling this space “nonargumentative]influence,” with two subtypes: “reason-bypassing” and “reason-countering.” Second, I argue that bioethicists have made the mistake of relying heavily on the conceptual categories themselves for normative work and instead should assess the ethical permissibility of a particular instance of influence by asking several key ethical questions, which I elucidate, that relate to (1) the impact of the form of influence on autonomy and (2) the relationship between the influencer and the influenced. Finally, I apply my analysis to two examples of nonargumentative influence in health care and health policy: (1) governmental agencies such as the Food and Drug Administration (FDA) trying to influence the public to be healthier using nonargumentative measures such as vivid images on cigarette packages to make more salient the negative effects of smoking, and (2) a physician framing a surgery in terms of survival rates instead of mortality rates to influence her patient to consent to the surgery. (shrink)

I investigate whether tobacco health warnings’ interference with autonomy is ethically justifiable in order to deter people from smoking. I dissociate first the informational role and the persuasive role of tobacco health warnings and show that both roles enable typical addicted smokers to better rule themselves, fostering their autonomy. The fact that some messages address people’s non-deliberative faculties is therefore compensated by a larger positive influence on their autonomy. However, misleading messages are not ethically justified and should be avoided. Tobacco (...) health warnings’ effect on autonomy highlights an important difference between libertarian paternalism and classical paternalism. (shrink)

In this response to Jonny Anomaly’s ‘Is Obesity a Public Health Problem?’ I argue, contra the author that public health 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 public health measures helping people make small changes in eating habits improve population health. I argue that (...) such measures are available to public health via behavioral economic research and policy proposals from libertarian paternalists. I respond to author’s claim that obesity does not constitute a public health 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 public health problem, but that obesity does have the status of an epidemic. I also point out flaws in author’s reasoning about obesity, public health and social costs. I conclude by suggesting that public health, 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 term ‘manipulation’ is frequently employed but rarely discussed or defined in psychiatric circles. This paper reviews previous conceptual analyses of the term by philosophers and psychiatrists, and examines its use in ordinary discourse. A series of characteristics which comprise the conceptual core of the term when it is unambiguously applied in interpersonal settings are proposed. Manipulation is contrasted with other behavior control methods such as rational persuasion and coercion, with emphasis on the role played by deception and the communicative (...) context in which the manipulative transaction occurs. It is argued that manipulative behavior is fundamentally intentional, and the usefulness of the concept of ‘unconscious manipulation’ is questioned. Though the proposal that Manipulative Personality Disorder be formally recognized as a new diagnostic category is rejected, it is urged that the concept of manipulation receive wider attention and discussion within the mental health community. (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)

Daniel C. Dennett is a brilliant polemicist, famous for challenging unexamined orthodoxies. Over the last thirty years, he has played a major role in expanding our understanding of consciousness, developmental psychology, and evolutionary theory. And with such groundbreaking, critically acclaimed books as Consciousness Explained and Darwin's Dangerous Idea (a National Book Award and Pulitzer Prize finalist), he has reached a huge general and professional audience. In this new book, Dennett shows that evolution is the key to resolving the ancient problems (...) of moral and political freedom. Like the planet's atmosphere on which life depends, the conditions on which our freedom depends had to evolve, and like the atmosphere, they continue to evolve-and could be extinguished. According to Dennett, biology provides the perspective from which we can distinguish the varieties of freedom that matter. Throughout the history of life on this planet, an interacting web and internal and external conditions have provided the frameworks for the design of agents that are more free than their parts-from the unwitting gropings of the simplest life forms to the more informed activities of animals to the moral dilemmas that confront human beings living in societies. As in his previous books, Dennett weaves a richly detailed narrative enlivened by analogies as entertaining as they are challenging. Here is the story of how we came to be different from all other creatures, how our early ancestors mindlessly created human culture, and then, how culture gave us our minds, our visions, our moral problems-in a nutshell, our freedom. (shrink)

One of six commentaries on “Obesity: Chasing an Elusive Epidemic,” by Daniel Callahan, from the January‐February 2013 issue.