Public Health Interventions: Ethical Implications
Abstract and Keywords
Public health interventions present distinct ethical challenges relative to clinical medical interventions, primarily because of their focus on prevention (rather than treatment) and their intended impact on the health of a population as a whole (rather than the individual). Public health interventions can be broadly categorized as falling into two main types: educational and environmental. Educational interventions aim to change individual behaviors, whereas environmental interventions seek to change the social and environmental conditions that encourage, require, or reinforce behaviors that are either beneficial or harmful to health. Public health interventions raise normative concerns with respect to three key ethical principles: the potential for harm (including stigmatization, lost opportunity costs, and threats to autonomy), justice, and social solidarity, particularly with respect to the problem of free riders. The high value placed on individual liberty in the modern era makes the task of asking individuals to give up freedoms to protect and promote population health increasingly difficult.
(p. 77) Definitions and Distinctions
According to a celebrated definition, “[p]ublic health is what we, as a society, do collectively to assure the conditions for people to be healthy” (IOM, 1988, 19). Although medicine and public health share the goal of improving health, they can be distinguished in at least four ways. First, whereas medicine is concerned with individual health, public health seeks to improve the health of the population as a whole. Second, whereas medicine is concerned with treating illness, public health focuses on prevention. Third, whereas physicians focus on internal physiological processes, public health professionals address interactions between people and their environment. Finally, whereas physicians rely on their professional authority to persuade patients to adhere to prescriptions, public health professionals may invoke the police powers of the state to compel compliance, under penalty of law. Each difference holds significant implications for public health ethics.
Public health interventions (PHIs) can be categorized along two axes: infectious versus chronic diseases, and interventions aimed at individuals versus those aimed the environment. Examples of infectious disease interventions that deliver services to individuals include immunizations and directly observed therapy (DOT) to prevent the spread of tuberculosis; infectious disease prevention interventions aimed at the environment range from processes to assure safe water and food supplies to insect vector controls. Chronic disease interventions aimed at individuals include smoking cessation and weight loss programs; chronic disease interventions targeting the environment include strategies such as restricting tobacco advertising or prohibiting indoor smoking.
To introduce one further distinction, infectious diseases are well described by the germ theory of disease, with an intrinsic relationship between exposure to an agent (e.g., a bacterium) and the development of a disease. To explain the onset of chronic (p. 78) diseases, however, epidemiologists had to redefine causality in terms of probabilistic risk factors. After searching in vain for decades for the agent responsible for cancer or heart disease, the now-famous Framingham Heart Study gave rise to a profound paradigm shift in the health sciences (Dawber, Meadors, and Moore, 1951). As the analysis of the data dictated, the “causes” of heart disease had to be redefined in terms of “risk factors.” A risk factor is neither necessary nor sufficient to cause disease; it only makes the onset of chronic disease more likely. A person can smoke and not get lung cancer, and people who get lung cancer need not have smoked. The one-to-one relationship between exposure to a specific agent and the onset of a particular disease thus gave way to the complex, multifactorial “neither necessary nor sufficient” risk factor analysis used to explain chronic diseases.
Chronic diseases account for the largest share of the burden of disease today (even in low- and middle-income countries) and they are responsible for more than 85 percent of the disease burden in high-income countries. Although there are important ethical issues in infectious disease control, this chapter focuses on the ethics of chronic disease interventions.
In addition to introducing the concept of risk factors to explain the occurrence of chronic diseases, the Framingham Study highlighted the significant role that human behaviors play in developing chronic diseases. Building on the 1964 report Smoking and Health (US Surgeon General, 1964) and the 1975 Lalonde Report, A New Perspective on the Health of Canadians (Lalonde, 1975), the 1979 US Surgeon General’s Healthy People report identified lifestyle behaviors as contributing “as much as half” to rates of morbidity and mortality in the United States, making it the first official statement to indicate that health behaviors are responsible for the greatest part of the disease burden in the country (US Surgeon General, 1979, 9). The role of behaviors in explaining mortality rates was later quantified in a famous article, “Actual Causes of Death in the United States,” by J. Michael McGinnis and William H. Foege (1993; updated by Mokdad and colleagues in 2004). Unhealthy behaviors, however, are not randomly distributed, but are instead strongly associated with social position, defined by income, race/ethnicity, and level of education. Thus, one key issue today is how to understand the interaction and relative weight that should be assigned causally to individual behavior choices compared to social structural factors in developing PHIs. For heuristic purposes, the different approaches can be termed “educational” and “environmental” interventions.
Educational and Environmental Interventions
Educational interventions are designed to change the knowledge, beliefs, and predisposing psychological and social factors that lead individuals to engage in unhealthy behaviors (e.g., starting to smoke, overeating). Virtually all current educational interventions acknowledge that information alone is not enough to produce the desired behavior change; to be effective, programs must address the antecedent social and psychological factors associated with initiating unhealthy behaviors. Examples of such factors include (p. 79) self-efficacy, perceived susceptibility, intentions, social support, and social norms (Glanz, Lewis, and Rimer, 1997; Glanz, Rimer, and Viswanath, 2008). The directionality of relationships among the identified factors and whether they are proximal or distal to the behavior of interest (for example, changes in social norms lead to changes in intentions, which in turn lead to changes in behavior) are often schematically depicted in diagrams, referred to as “logic models” in the field, which provide the basic blueprint for designing educational programs (Green and Kreuter, 1991; Funnell and Rogers, 2011).
With growing appreciation of the effects that social context has on the distribution of disease, attention has turned to developing interventions that address the social determinants of health. The “social determinants” of health and disease have been variously identified, but they generally include levels of poverty, racism, education, employment, housing quality, neighborhood environment, inequalities in wealth and status, stigmatization, access to healthy foods, access to medical care and recreational areas, and access to transportation (Wilkinson and Marmot, 2003; Marmot, 2005; Blas and Kurup, 2010). Recognition of the importance of the social determinants is duly credited to the epidemiologist Michael Marmot and his pioneering Whitehall studies dating to the 1970s (Marmot and Winkelstein, 1975; Marmot et al., 1978). Marmot found a highly robust linear relationship between social class (as defined by the British employment classification system) and health status, across virtually all disease categories, despite access to health care through national health coverage. His work was highly influential in informing the British Department of Health and Social Security (DHSS) report Inequalities in Health (commonly referred to as the “Black Report”), released in 1980. The Black Report examined four alternative hypotheses and concluded that the cause of health inequalities was differences in material conditions and income (DHSS, 1980; Blane, 1985).
Short of eliminating poverty, a variety of strategies have been developed under the umbrella of environmental interventions. Whether inadvertently, through technological advances such as television and automobiles, or intentionally, through advertising or product placement, physical and social environments have been transformed in ways that are far less conducive to optimal health (for example, such changes have led to people driving instead of walking to work, or children watching TV instead of playing outside). To protect and promote population health, environmental interventions seek to undo or counterbalance these untoward changes in the environment. This approach has gained popular attention in the concept of “nudges,” developed by Thaler and Sunstein (2008). One example of the use of nudges is to re-engineer cafeteria lines to feature fresh fruits more prominently, instead of the more typical conspicuous displays of candy and chips.
Key Ethical Concerns in Chronic Disease Control
A number of normative frameworks have been disseminated in recent years to identify, analyze, and weigh different ethical considerations in evaluating PHIs (Kass, 2001; Petrini, 2010; ten Have et al., 2010; Childress et al., 2002; Marckmann et al., 2015). Because (p. 80) of their distinctive characteristics, PHIs raise different and complex trade-offs in balancing key ethical principles than do the ethical challenges raised in medical care. Based on criteria enumerated in these frameworks, PHIs to prevent chronic diseases are liable to raise significant ethical concerns with respect to issues of harm, including threats to individual liberties, justice, and the problem of free riders in relation to social solidarity.
Three types of harms have been identified in normative analyses of chronic disease control interventions (CDC, 2004). The first pertains to the potential for stigmatizing people who engage in unhealthy behaviors, especially in mass media campaigns. The second pertains to potential opportunity costs, where the implementation of one particular PHI may come at the cost of sacrificing other possibilities. The third, and most common, concern pertains to potential infringements on individual liberties.
In developing campaigns that go beyond merely providing factual information, one of the most problematic “educational” interventions involves the use of shame to motivate behavior change. This approach is found in some campaigns against smoking and obesity (Kim and Shanahan, 2003; Brown-Johnson and Prochaska, 2015). For example, Children’s Health Care of Atlanta ran a campaign that put up billboards portraying youth with excess weight along with “warning” signs proclaiming “Stocky, Chubby, and Chunky Are Still Fat,” or “Fat Kids Become Fat Adults” (Puhl, Peterson, and Luedicke, 2013a, 2013b). The concern is that such campaigns do more harm than good, not only by failing to motivate people to lose weight, but also by actually damaging their mental health. Burris (2008, 475) argues that it is never acceptable to invoke stigma intentionally as a “visceral mode of social control.”
However, Bayer (2008, 463) has posed provocative questions about campaigns to “denormalize” tobacco use, asking, “Are there occasions when the mobilization of stigma may effectively reduce the prevalence of behaviors linked to disease and death?” Even more pointedly, he asks if the state can legitimately “engage in efforts that have as their intended goal the stigmatization of such behaviors through campaigns that attempt to tap the power of shame and guilt to affect social norms” (468). There is in fact some evidence indicating that stigma is effective in stimulating individuals to lose and sustain weight loss (Latner et al., 2009).
As the different positions recited here indicate, the line between stigmatization and denormalization is indistinct and contested. Yet the argument seems to rest on a utilitarian calculus: Do the benefits of weight loss outweigh concerns about making people feel bad about themselves? How bad do they have to feel before it becomes unacceptable? In a broader perspective, one must ask whether the goals themselves are being deformed by such methods: Is the goal of public health exhausted by a set of empirical measures of physical fitness, or does the goal necessarily need to incorporate the normative (p. 81) dimensions of justice, respect, and autonomy? To what extent is it appropriate for the field of public health to concern itself with preserving human dignity and self-respect? We return to such deontological considerations in the conclusion.
The issue of opportunity costs arises when an intervention competes against other priorities (Brody, McCullough, and Sharp, 2005). Based on utilitarian calculations of the leading causes of mortality and the most significant behavioral risk factors, government agencies have made major investments in tobacco and obesity prevention programs. But community activists voice concerns that such programs detract attention and resources from other acute problems, such as violence and substance use (Wolff et al., 2003). Similarly, even sympathetic observers have noted that the huge investment in antiretroviral therapies in international settings has diverted resources away from other urgent health problems, such as the dramatically increasing prevalence of diabetes (England, 2008).
Threats to Individual Liberties
Concerns about whether PHIs unduly infringe on individual liberty have been a central theme in public health ethics debates since the landmark 1905 Jacobson v. Massachusetts Supreme Court ruling, which found that the state could compel individuals to be vaccinated against smallpox. The historic ruling thus recognized the legal authority and ethical validity of the use of state power to constrain individual liberties to protect the common good (Gostin, 2002).
Calls for new taxes and bans on large soda bottles are only the most recent examples of PHIs to raise questions about potential infringements on individual liberties, provoking charges of paternalism. Paternalism is defined as “interference with a person’s liberty of action justified by reason referring exclusively to the welfare . . . of the person being coerced” (Dworkin, 1999, 121).
Environment interventions, in general, pose a greater threat to individual liberties than educational interventions, since persuasive messages to behave prudently are generally considered benign and a legitimate function of government. Interventions designed to abate market-induced incentives or to hinder people from making unhealthy choices by penalizing such choices or imposing environmental constraints present more complex challenges. Moreover, when public health professionals lobby to raise taxes on cigarettes and soda, opponents argue not only that they impinge on personal liberties, but also that the burdens of taxation fall disproportionately on the poor, thus raising issues of fairness and justice (Resnik, 2013; Arno et al., 1996; Hoffman and Tan, 2015; Guindon, 2014; Nestle and Bittman, 2015; Pomeranz, 2012). In light of such concerns, Kass (2001) notes that as the potential burdens of PHIs increase, the value of the goals to be achieved should be proportionately more compelling.
In examining these issues, it is important to note that many alleged infringements on individual liberties rest on the dubious assumption that the government is unduly seeking to alter a pristine environment. Most democratic citizenries, however, have (p. 82) largely passively allowed powerful corporations to shape the environment to advance their interests (e.g., by placing billboards along highways, or placing candy and chips at supermarket checkout counters). While many people appreciate the convenience and affordability that the market provides, others recognize that a collective interest in protecting health often outweighs the modest threats posed by undoing modifications in the environment in order to encourage healthy choices (e.g., by restricting the placement of billboards). Although Sunstein and Thaler’s “libertarian paternalism” may sound like a contradiction in terms, it is based on an appreciation that life would simply be too exhausting if people had to deliberate consciously and carefully about every choice they had to make throughout the day (see also Kahneman, 2013). It is in the collective interest of society to think about how to structure the environment to make routine decisions—choices that people do not need, nor want, to rise to the level of conscious deliberation—less hazardous, rather than allowing the choice architecture to be set up solely to serve market interests.
Balancing individual and collective interests raises the issue of respect for the autonomy of the community as a whole. In medicine, individual patients must affirm their voluntary informed consent before undergoing treatment. With PHIs, an equivalent procedure for providing the informed consent of the population affected has not been established. Out of respect for the community’s right to self-determination, public health officials have an obligation to assure that there is a high degree of public consensus supporting claims that the health benefits of an action outweigh costs to individual liberties. While it is common for a majority of people to agree to adopt restrictions, it is important to recognize that they are justified only provisionally, by ratification in the court of public opinion, until such time that new evidence leads to reconsideration. Public health advocates can lobby for banning the sale of large sugary drinks, but its ethical warrant lies in convincing a majority of the public that the health benefits outweigh other legitimate moral considerations (Habermas, 1984). Childress et al. (2002) recommend that, other things being equal, public health professionals should opt for the least restrictive approach.
The ethical justification for PHIs is inextricably intertwined with questions of justice. Although public health is often alleged to be intrinsically utilitarian (the greatest good for the greatest number), there are today prominent calls for social justice in the field. This entreaty was issued in an acclaimed paper by the political scientist Dan Beauchamp, titled “Public Health as Social Justice” (1976). Beauchamp cites the political philosopher John Rawls as his source of inspiration, and many public health professionals today loosely subscribe to a Rawlsian egalitarian theory of justice. The importance of promoting equality was featured in the US Surgeon General’s Healthy People 2000 report, which contained the first official statement that the goal of US Public Health Service was to “reduce health disparities” (US DHHS, 1990). This goal was strengthened to “eliminating” health disparities in Healthy People 2010, and reiterated in Healthy People 2020 (US DHHS 2000, 2010).
(p. 83) Since the original Healthy People 2000, there has been growing recognition that one problem with the goal of eliminating health disparities is that differences in health have many causes, only some of which can be considered the result of unjust social arrangements. Genetic diseases, for example, result in significant health disparities, but they are not the result of corrigible social conditions. While the higher prevalence of sickle cell anemia in African American populations is tragic, its distribution is not a matter of the justice of social conditions. As these incongruities have become better appreciated, there has been a shift in terminology toward the use of “health equity,” and hence in eliminating health inequities (Baker, Metzler, and Galea, 2005; Braveman and Gruskin, 2003).
In a significant extension of Rawls’s work, Norman Daniels (1985, 2001, 2008) argues that if liberal democratic societies have a duty to protect fair equality of opportunity, then they must also have a duty to maintain the normal functioning of human beings. To the extent that disease and disability impair normal functioning, they restrict the range of opportunities open to individuals. It is therefore essential to preserve and restore normal functioning so that people can participate in the social, political, and economic life of society. While the threat to individual liberties must always be kept in mind, public health interventions find justification not only in protecting physical health, but also in enabling people to participate in social and political life without undue impairment, as a matter of justice.
Rawls’s theory of justice has been criticized by those who advocate an even stronger egalitarian position, generally referred to the “capabilities approach.” Its most prominent exponents are Amartya Sen (1999a, 2009) and Martha Nussbaum (1990, 1993, 2011). From a capabilities perspective, it is insufficient that social institutions be arranged such that they merely provide the opportunity for individuals to pursue their life plans, because those opportunities are cruel fictions unless people possess the capability to fulfill their plans successfully. Here, the key question of justice concerns what people are actually able to achieve. If people’s abilities are so stunted by existing social conditions that the range of opportunities—those that they actually able to pursue—is severely constricted, then one cannot claim to live in a just society, no matter how much people may believe that they have fair opportunity. Rather, a just society is obligated to enable everyone to have the same capacity to pursue the full range of occupations and recreational activities that the most well-off segments of society enjoy, a position that Sen refers to as “substantive freedom” (Sen, 1999b).
Free Riders and the Dilemmas in Social Solidarity
One final topic reflective of key ethical tensions in PHIs lies in the dilemmas of buttressing social solidarity, an issue salient now in the withdrawal of participation from universal immunization protections. The normative issue at stake here is the problem of so-called free riders. The free rider problem refers to the ethical dilemma that arises when some people choose to not contribute an equal or fair share to a given cooperative scheme, but (p. 84) instead count on being able to take advantage of the benefits of the system without doing their part to maintain its overall strength. As the 2015 outbreaks of measles and rubella attest (Clemmons et al., 2015; Majumder et al., 2015), growing numbers of parents are choosing to not get their children vaccinated. Similarly, people know that smoking and obesity raise health insurance premiums, which has triggered fraught public debates about whether or not smokers should be required to pay more. In their analysis of social solidarity, Dawson and Verweij (2012) identify two types, rational and constitutive. They argue that public health has relied on rational solidarity, but it may be better served by promoting constitutive solidarity. Both forms face daunting challenges, albeit with pressures from different directions.
Rational solidarity is realized by means of an implied social contract. People agree to pay taxes and pool resources in order to protect one another from serious and unpredictable health threats, buying in on the tacit assumption that everyone has a rational self-interest in keeping their individual expenditures (whether taxes or health insurance premiums) as low as possible. When people knowingly engage in risky behaviors, however, they break the contract, forcing the rest to have to pay more to cover the additional health care costs incurred. They act like free riders, and thereby undermine rational solidarity.
In contrast, constitutive solidarity is forged out of a shared sense of identity. People choose to stand together, not due to some rational cost-benefit analysis for maximizing individual interests, but through positive identification with fellow citizens, based in part on norms of sympathy for the pain and suffering that all must endure. It is a rare person who is not cognizant of the fragility of the human condition and the capriciousness of being stricken by disease. People know that no one has complete control over their health, and so they see each other sharing a common human fate. But where rational solidarity suffers the free rider problem, constitutive solidarity is undermined by social injustices.
There is general public awareness that health risk behaviors are not randomly distributed, but rather are strongly associated with income, race, and level of education. One plausible explanation for these patterns is that they are reflective of the distribution of stress across different social groups (Geronimus et al., 2006). Among other explanations, in one provocative analysis, Factor, Kawachi, and Williams (2011) suggest that members of minority groups react with feelings of frustration and anger at the inequitable distribution of societal benefits and burdens. As a result of their exclusion from a fair share of social benefits, and the disproportionate imposition of its burdens (poverty, unemployment, etc.), some low-income minorities flaunt calls to conform with dominant social norms, taking up drug use, unprotected sex, and other activities, and in the process signaling their resistance and rejection of dominant codes of behavior (Cohen, 2004). When socially identifiable groups are forced to bear an inequitable share of the burden of participating in a particular cooperative scheme, they become alienated and disenfranchised, no longer feeling that the dominant majority identifies with them or sees them as belonging to the same membership group, entitled to the same benefits and protections (Shelby, 2015, 2016). Constitutive solidarity cracks under the strains of social injustice.
The social solidarity necessary for collective action on behalf of the population as a whole is thus being battered on many sides. The broad secular trend toward valuing (p. 85) individual authenticity—of finding one’s true and unique self, free from the strictures of social identities and normative demands—feeds the ranks of free riders and reinforces antinomian predilections (Appiah, 2005; Taylor, 1992). The tolerance of poverty and growing social and economic disparities warp the development of the capacity to exercise positive self-determination among those bearing the brunt of those burdens. Never was there a more important time for thinking seriously about the grounds for forging collective action and enacting provisions based on communal identifications and a shared sense of social responsibility.
Public health interventions raise profound questions about individual rights, the obligations of members of collectivities toward one another, and the nature of justice and the just society. As the different issues reviewed here indicate, it is generally not enough to invoke a simple utilitarian calculus in determining whether the overall health benefits of a proposed intervention outweigh the threat of unintended morbidities or deaths. Public health authorities have an obligation to respect both the individual’s and the community’s right to self-determination. If most chronic diseases these days are strongly associated with individual behaviors, to what extent is it ethically appropriate and justified to shame people or to invoke the police powers of the state to reduce their occurrence?
More poignantly, if such behaviors are in turn strongly associated with income, race, and level of education, to what extent does society have an obligation to improve social conditions for the sake of achieving reductions in morbidity and mortality rates? Further still, are there other more compelling reasons to improve social conditions? Is it possible for modern liberal democracies to tackle questions about human dignity, beyond empirical measures of death, disease, and disability? Does “health” entail an essential ethical dimension (as often implied in the shift to the term “well-being”), where the goal of social interventions is not only to enable people to live longer, but also to enjoy a higher quality of life, one defined by dignity and respect, free from the indignities of feeling inferior? If public health is social justice, then it is incumbent upon the field to implement interventions that create a space in civil society for promoting dialogue and expanding the sphere of consensus around the kind of society we want to live in together (Buchanan, 2008).
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