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- Herausgeber: John Wiley & Sons
- Kategorie: Geisteswissenschaft
- Sprache: Englisch
The study of public health aims to protect and promote the wellbeing of the public as well as reduce health inequalities. Public health ethics asks how far we should go to achieve these goals, balancing the rights and needs of individuals against those of the community. But what are these and how much weight should be given to each of them? In the third edition of his well-loved textbook, Stephen Holland shows how philosophy is key to evaluating the suitability of public health interventions. Holland explores the key goals of public health ethics in relation to both moral and political philosophy, reflecting on our everyday intuitions about which public health policies are justified. In light of recent developments, he includes new content exploring equity and health inequalities, and on how public health information is gathered and used. The book is updated throughout with material on contemporary cases, such as the COVID-19 pandemic. Public Health Ethics continues to provide a lively, accessible and philosophically informed introduction. As well as being an ideal student text, Holland's systematic discussion will engage the more advanced reader and inform scholarship in the field.
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Veröffentlichungsjahr: 2022
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CONTENTS
Cover
Dedication
Title Page
Copyright
Introduction
Part I: Moral and Political Philosophy
Introduction to Part I
1 Consequentialism
Defining consequentialism and utilitarianism
The naïve utilitarian view of public health
Concluding remarks
2 Non-consequentialism
Deontology
Virtue ethics
Principlism
Concluding remarks
3 Liberal Political Philosophy
Liberalism
Liberalism and Mill’s harm principle
Freedom: positive and negative conceptions
Concluding remarks
4 Beyond Traditional Liberalism
Libertarian paternalism
Non-liberal political philosophy: communitarianism
Concluding remarks
Part I Summary
Part II: Fundamental Aspects of Public Health
Introduction to Part II
5 Epidemiology and Public Health Information
Theoretical challenges to epidemiology
Epidemiology, health information and ethics
Ethics and governance of public health information
Concluding remarks
6 Health Concepts
Is the nature of health important in public health ethics?
First conceptual claim: ‘health’ is ambiguous
Second conceptual claim: health is an evaluative concept
Public health and the ambiguous nature of ‘health’
Concluding remarks
Part III: Public Health Activities
Introduction to Part III
7 Health Promotion as Behaviour Modification
What is ‘health promotion’?
Health promotion as behaviour change
Ethics and behaviour modification techniques
Justifying interventions to modify health behaviours
Concluding remarks
8 Harm Reduction
Introducing harm reduction
The ethics of harm reduction
Harm reduction: some cases
Concluding remarks
9 Immunization
Vaccination ethics
Liberalism and the harm principle
The duty not to infect others
Free-riding
Concluding remarks
10 Screening
Screening programmes
Generic issues
Benefit
Concluding remarks
Concluding Remarks
The re-description problem
Public health ethics and philosophy
References
Index
End User License Agreement
Guide
Cover
Table of Contents
Dedication
Title Page
Copyright
Introduction
Begin Reading
Concluding Remarks
References
Index
End User License Agreement
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Dedication
For Louise, Reuben, Arianne and Solomon
Public Health Ethics
Third Edition
Stephen Holland
polity
Copyright © Stephen Holland 2023
The right of Stephen Holland to be identified as Author of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
First published in 2007 by Polity Press
This edition published in 2023 by Polity Press
Polity Press65 Bridge StreetCambridge CB2 1UR, UK
Polity Press111 River StreetHoboken, NJ 07030, USA
All rights reserved. Except for the quotation of short passages for the purpose of criticism and review, no part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher.
ISBN-13: 978-1-5095-4831-6
A catalogue record for this book is available from the British Library.
Library of Congress Control Number: 2022939156
The publisher has used its best endeavours to ensure that the URLs for external websites referred to in this book are correct and active at the time of going to press. However, the publisher has no responsibility for the websites and can make no guarantee that a site will remain live or that the content is or will remain appropriate.
Every effort has been made to trace all copyright holders, but if any have been overlooked the publisher will be pleased to include any necessary credits in any subsequent reprint or edition.
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Introduction
THE distinctive characteristic of public health is its population perspective. In contrast to the focus on individual patients typical of clinical medicine, public health brings into view entire populations, or sizeable subgroups within a wider population. The main aims of public health are to monitor the health of communities, identify causal factors in public health, and devise and implement programmes to maintain or improve the health of the population. Specific types of public health activities include mass immunization campaigns, screening programmes and health promotion. Public health aims to reduce health inequalities within and between populations, and recognizes the multidimensional nature of health determinants and the complex interaction of factors – biological, social, environmental, etc. – that influence health status. Relatedly, public health is a multi-agency endeavour backed by the executive and legislative powers of the State. The basis of public health is empirical data acquired by epidemiological research and population surveillance; although the ultimate goal is to save and improve real lives, the success of public health is measured by statistical lives and rates of incidence of disease.
Because public health takes the population perspective, it creates distinctive ethical challenges, not just moral problems already familiar from related disciplines such as medical ethics and bioethics. In particular, public health sometimes promises benefits to populations at a cost to individuals. This can create dilemmas between the rights and needs of individuals and the rights and needs of the community. Of course, such dilemmas neither always nor necessarily arise because, happily, the rights and benefits of individuals and communities often coincide. Nor is public health unique in this regard, because dilemmas between individual and community arise in other contexts where public and private interests interface. Nonetheless, a central concern in public health ethics is the trade-off that can arise between protecting and promoting the health of populations, and various kinds of costs to individuals, including physical risks and moral harm.
Given the distinctive nature of public health ethics, it would be a mistake simply to apply findings from medical ethics and bioethics to ethical issues in public health. In particular, the main achievements in medical ethics and bioethics are due to an increased awareness of, and concern to protect, individual rights – such as an individual’s right to consent to participate in medical research, or to receive medical treatment – grounded in the principle of respect for autonomy. But, as just outlined, the distinctive thing about public health ethics is the dilemma that can arise between individual rights and community benefit. So, simply to apply the guiding principles of medical ethics and bioethics to the field of public health ethics would be to beg the question by assuming the priority of individual rights over communal benefit, when it is precisely the relative value of these that forms the core ethical question in public health. Consequently, public health ethics requires more imagination than borrowing templates from medical ethics and bioethics.
In recognition of this, public health ethics has developed over recent decades into a distinctive discipline. Prior to the 1990s, some medical ethicists were alert to the relevance of ethics to public health (Lappé 1983; Beauchamp 1985); some public health activities occasioned sustained ethical debate, such as health promotion (Williams 1984) and screening (Skrabanek 1988); and new public health challenges, notably the HIV/AIDs pandemic of the 1980s, raised serious ethical questions (Levine and Bayer 1989). But around 1990 it became increasingly clear that the ethical dimension of public health had been underplayed, motivating a more concerted academic effort (Skrabanek 1990; Horner 1992). In another upsurge of interest around 2000, scholars and public health practitioners analysed the ethical aspects of public health more closely (Callahan and Jennings 2002; Roberts and Reich 2002). Since then, public health ethics has become firmly established, including substantial academic research output, and a commitment to public health ethics as part of academic and practical training curricula (Coughlin et al. 1999; Viens et al. 2020). This sharper focus on the ethics of public health has informed Guidelines and Codes of Conduct for public health practitioners (Thomas and Miller 2017).
A consistent theme throughout this development of public health ethics is the requirement to evaluate public health interventions in order to determine whether they are justified. This was recognized very early on – as Horner (2000: 52) put it: ‘Every proposed new public health intervention should be carefully evaluated for its “ethical dimension”’ – and continues up to the present (Holland 2021). This is the principle focus of this book: public health ethics is about evaluating, in order to justify, public health interventions. Of particular concern, given the problem just mentioned of ‘individual versus community’ that can arise in public health, are interventions that impose on individuals by infringing their rights and freedoms. Such interventions are especially contentious in countries with liberal political cultures – such as those in Europe and the US – particularly when they have governmental support. Classic examples of such interventions include legislation to ban certain substances or activities, such as unhealthy food and beverages, or smoking in public places, and the range of measures introduced in response to the Covid-19 pandemic, such as ‘lockdowns’ and quarantining rules, which severely restrict people’s movements in order to reduce disease transmission.
This way of framing public health ethics has been criticised in a number of ways, some of which can be briefly addressed here (Dawson 2009, 2010; Holland 2021). One is that the focus on interventions ignores social determinants of health, i.e., ‘conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life’ (World Health Organisation 2021). But evaluation of interventions should be informed by, not exclude, social determinants of health. For example, it is vital to take into account the disparate impact of policies on different social groups when evaluating public health programmes. Another concern is that, in evaluating public health policies, individual rights and freedoms will trump public health concerns and values, such as heath inequalities and solidarity. But the point is to balance such considerations, not bias evaluations by making a presumption in favour of individual liberty or the right to non-interference (hence the numerous non-liberal approaches, such as communitarianism, canvassed in this book, and the commitment to ‘reflective equilibrium’, as explained below). A wider concern is the focus on Western-style democracies to the exclusion of low- and middle-income countries, when there are unacceptable disparities in health outcomes between rich and poor parts of the world. But public health activities in countries such as the US and in Europe require scrutiny, especially when they are intrusive and backed by State power, and crucially, this is not inimical to a more radical agenda of global reform.
All this is illustrated and vindicated by the current Covid-19 pandemic and the public health response, which includes lockdowns, travel bans, quarantining measures and requirements on individual behaviour, such as social distancing rules. These are unusually intrusive public health interventions, and unusually extensive exercises of State power, so they need to be evaluated to see whether they are justified. But to do so is not to ignore social determinants of health; on the contrary, the disparate impact of Covid measures, for example, is of central concern when evaluating them. Likewise, the fact that Covid measures such as lockdowns restrict individual liberties gets the analysis going, but there is no presumption in favour of liberty over other public health goals and values. And although the justification for such measures is particularly focused on liberal, Western-style democracies, this is not inimical to global concerns, such as ‘vaccine nationalism’ (i.e., wealthy nations prioritize their population’s access to vaccines at the expense of fair global distribution; see Zhou 2022).
How are such public health interventions to be evaluated? Some approaches firmly embedded in the literature will not be taken here. One is to construct an ethical framework specific to public health. For example, Kass (2001) proposed a six-step framework, ‘an analytic tool, designed to help public health professionals consider the ethics implications of proposed interventions, policy proposals, research initiatives, and programs’. Similarly, Childress et al. (2002) proposed five justificatory conditions ‘to help determine whether promoting public health warrants overriding such values as individual liberty or justice’, namely, effectiveness, proportionality, necessity, least infringement and public justification (p. 173). There are lots of good things about this – and proposing frameworks was important for the development of public health ethics as a discipline – but ‘framework’ is a metaphor that implies an extant and rigid construction, which would be insufficiently flexible given that any framework may fit badly with new ethical challenges in public health.
Another established approach to public health ethics, particularly prominent in global public health, is via human rights (Mann 1995; Gostin and Meier 2020). Again, although there is much to applaud about this, there are problems with a rights-based approach. There is no consensus on the content or force of human rights, and rights that are established can conflict with one another. Practically speaking, who can be trusted to protect rights, given that States often fail in this regard and it is unlikely that some other institution will fill the vacuum? The biggest conceptual difficulty is that rights are notoriously ambiguous, and the only way to disambiguate rights is to determine the obligations that a putative right enshrines. An example of O’Neill’s (2002: 42) is that the only way to interpret a putative right to health care is to determine ‘who has to do what for whom’; but this implies that obligations, not rights, are fundamental, so to take rights as basic to ethics ‘does not get close enough to the action’. There is also a danger of merely restating the dilemma at the core of public health ethics – i.e., between individual and community – in terms of rights. For example, a human right to maximal health status would require interventions to improve population health, but if such interventions transgress individual rights (to privacy, liberty, confidentiality or whatever), the question arises as to which is the more important right, the human right to maximal health or the individual right to (say) privacy? But this is just the core dilemma in public health ethics again, put in terms of rights.
To reiterate, there is much to applaud about approaching public health ethics via frameworks and rights. Classic frameworks, such as Kass’ and Childress et al.’s, identify important things to consider when evaluating interventions. And rights are typically more effective than moral judgements, because they can be enshrined in law and backed by legal sanction; notably, they seem particularly well suited to certain issues, especially those involving global justice, such as the current issue of vaccine nationalism and fair access to Covid-19 vaccines (Beyrer et al. 2021). This suggests that the best way forward is to be aware of, and remain open to, various approaches, rather than thinking we have to adopt one to the exclusion of others. In turn, this ushers in the approach recommended in this book, namely, ‘reflective equilibrium’.
To explain reflective equilibrium – for a fuller explanation, see Holland (2021) – recall the question as to how to go about evaluating public health interventions to see whether they are justified. The idea behind reflective equilibrium is that we should do this by bringing three sorts of considerations into equilibrium. The three sorts of considerations are relevant theories, mid-level principles and beliefs about specific cases. Relevant theories and mid-level principles are covered in part I of this book, so we revisit reflective equilibrium at the end of part I. For now, just to illustrate, an example of a relevant theory is utilitarianism, which roughly states that a public health initiative is justified if it maximizes benefit. An example of a mid-level principle is the principle of equity, which roughly states that we ought to prefer public health policies that reduce rather than worsen unjust health disparities. An example of the third sort of consideration, beliefs about specific cases, would be what people think, on reflection, about introducing vaccine passports in response to the Covid-19 crisis.
Let’s continue to take Covid-19 vaccine passports as our illustration of bringing these three sorts of considerations into reflective equilibrium. A vaccine passport is some kind of documentary evidence of having been vaccinated against Covid-19, as a condition of, for example, access to events (such as sporting events) or venues such as night clubs, or of being allowed to return to work or travel abroad. Our aim is to evaluate this public health policy. Reflective equilibrium consists of reflecting on the way these three considerations interact regarding this policy. Crucially, this is an iterative process: we continually adjust our commitments to the three sorts of considerations until we arrive at a settled view as to whether vaccine passports are justified. Suppose, for example, we start out wedded to utilitarianism, the equity principle, and the belief that vaccine passports are a good idea (there will be lots of other theories, principles and beliefs too, but this will do as an illustration). We might quickly realise that these three commitments are in disequilibrium: utilitarianism tells us to support the policy, because it maximizes benefit; but it will worsen health disparities; and our pre-theoretical belief was that it is a good policy. This realization starts the process of reflective equilibrium: which of these three commitments are we going to revise in order to bring theory, principles and beliefs into equilibrium? To illustrate, we might end up so wedded to the belief that vaccine passports are justified that we have to adjust our commitment to the equity principle. Alternatively, we might be so committed to health equity that we have to adjust our views on utilitarianism and our belief that vaccine passports are justified.
The advantages of reflective equilibrium as a methodology are that it allows us to include theories, principles and considered judgements when evaluating public health policies; it is sufficiently flexible to apply to the wide range of interventions required in public health; and it avoids dogmatically applying one particular theory or principle (such as utilitarianism, or the equity principle), or taking one approach in public health ethics to the exclusion of others. All three parts of this book can be related back to this methodology.
Part I explains the moral and political philosophy, and ethical principles, most pertinent to public health ethics. Part II addresses two themes, namely, health information and the concept of ‘health’. These are relevant to the evaluation of all public heath interventions, because any intervention will be based on collecting and using information and data, and will (implicitly or explicitly) define health in a certain way. Part III looks at ethical considerations particular to four key public health activities – health promotion, harm reduction, immunization and screening – because such ethical considerations should be included in the process of reflective equilibrium by which specific public health policies are to be evaluated.
Part IMoral and Political Philosophy
Introduction to Part I
THE aim of part I is to introduce, explain and discuss the moral and political philosophy most pertinent to public health ethics. It is important to have a clear overview of these first four chapters. First, we need to distinguish between moral philosophy, on the one hand, and political philosophy on the other. Chapters 1 and 2 deal with moral philosophy; Chapters 3 and 4 deal with political philosophy. Second, we need to be clear about how the material in part I is organized. The discussion gets going with what will be called the naïve utilitarian view of public health. Utilitarianism is a consequentialist moral theory (such jargon is fully explained below) that says, roughly, the right thing to do is that which will maximize benefit. The naïve view is that any public health intervention is fully morally justified on the utilitarian grounds that it produces benefit by protecting and promoting the public’s health. All the material discussed in part I can be related back to this view. First, chapter 1 criticizes this naïve utilitarian view of public health by discussing considerations from within the same moral-philosophical framework to which it belongs, i.e., from within consequentialism. So, the rest of chapter 1 explains more sophisticated versions of utilitarianism in order to query the naïve utilitarian view.
Chapter 2 is similar to chapter 1 in that it, too, queries the naïve utilitarian view of public health. Also, it does so by appealing to theories in moral philosophy. But the important difference is that chapter 2 moves beyond the consequentialist framework to which utilitarianism belongs by discussing non-consequentialist considerations that count against the naïve view. Specifically, three non-consequentialist moral theories which are very important to public health ethics, and which put pressure on the naïve utilitarian view, are explained and discussed. The first is called deontology (again, such unfamiliar jargon words are fully explained below). Deontology captures the idea that a public health intervention might be unethical just because of the kind of intervention it is, as opposed to anything to do with its consequences. Famously, Immanuel Kant developed a sophisticated deontological moral theory; Kant’s theory is introduced in chapter 2, where its application to public health ethics is illustrated.
The two other non-consequentialist moral theories discussed in chapter 2 are virtue ethics and principlism. The basic idea behind virtue ethics is that morality is a matter of character; specifically, right action is that which would be undertaken by the moral agent who acquires virtues, such as kindness and courage, and exercises them appropriately. This theory might seem too personal to be of much relevance to public health. Also, appealing to virtues in ethics might seem to lack the sort of clarity about how to act that we find in utilitarianism and Kantianism. But, on the contrary, virtue ethics is frequently invoked in public health ethics, some writers arguing that it is the most important approach, and as we shall see – for example, in the discussion of epidemiological ethics in chapter 5 – virtue ethics is certainly pertinent to contemporary public health practice.
Principlism is very well known in medical ethics because of an influential book by Beauchamp and Childress that has been updated and published numerous times, called Principles of Biomedical Ethics. Their original idea is that certain principles are particularly pertinent to ethical problems that arise in biomedicine, so a proper discussion of such problems requires clarifying these principles and seeing how they apply in particular cases. Principlism has many strengths as an approach to biomedical ethics, but how well does it apply to public health? It is argued in chapter 2 that Beauchamp and Childress’s original biomedical principles are not well suited to public health; nonetheless, principlism is still important because other principles, better suited to public health ethics, can be developed. These other principles are explained and discussed, and their application illustrated.
So, by the end of chapter 2 we will have considered both consequentialist and non-consequentialist grounds for querying the naïve utilitarian view that all public health interventions are justified by protecting and promoting the public’s health. Chapter 3 is in the same vein, but there are two important things to note here. First, as mentioned above, chapter 3 moves beyond moral philosophy and into political philosophy. Second, chapter 3 starts with an argument called the liberal objection. The liberal objection to public health interventions is based on the claim that they amount to an assault on individual liberties. So, as with the material in chapters 1 and 2, here we have a response to naïve public health utilitarianism: liberty-limiting public health interventions are objectionable infringements on individual freedoms, whatever other good consequences they might have in terms of protecting and promoting the health of populations.
The question central to chapters 3 and 4 is, how strong is the liberal objection to public health intervention? First, the political philosophy from which the liberal objection emanates, namely, liberalism, is defined. This is not such an onerous task because liberalism is the familiar backdrop to our Western political culture and institutions. Then, grounds for questioning the strength of the liberal objection are considered. First, grounds for questioning the strength of the liberal objection found within liberalism itself are discussed in chapter 3. One such is especially important in public health ethics, namely, Mill’s harm principle. Bluntly, the harm principle says that the State is justified in interfering in individual liberties to avoid harm to third parties. This has proved enormously influential in Western political culture in general, and it is frequently appealed to in public health ethics. The principle is explained in chapter 3, where its impact on the liberal objection is discussed. Another way of querying the liberal objection – again, still within the liberal tradition – focuses on how to understand the concept of freedom. The liberal objection assumes that freedom is merely the absence of constraints on individual choice. This is known as a negative conception of freedom because it defines freedom as the absence of something (i.e., constraint). But there are plausible positive conceptions of freedom, some of which are canvassed in chapter 3. The liberal objection looks much less compelling when freedom is defined positively.
Chapter 4 continues to apply political philosophy but here we move out of the traditional liberal circle of ideas to critique the liberal objection. First, we look at a recent and influential attempt to combine the liberal insistence on individual freedom with the paternalistic urge to get people to behave in their own best interests. This is ‘libertarian paternalism’ but it is also known by the less technical term, ‘nudge’. Theoretical objections to, and applications of, ‘nudging’ are discussed. In the latter part of chapter 4, liberalism is juxtaposed by a non-liberal political philosophy known as communitarianism. Communitarians criticize liberals for unreasonably emphasizing the individual and their freedom of choice. The general aim of the communitarian critique of liberal individualism is to re-establish the communal goods and values suppressed by liberalism’s emphasis on individuals and their rights. Some of the details of this critique are explained, and its influence on public health policy evaluated.
1Consequentialism
THIS chapter starts by explaining the theory in moral philosophy called consequentialism. Then a specific version of consequentialism, i.e., utilitarianism, is clarified. Given this, the naïve utilitarian view of public health can be presented. The naïve view is that policies and programmes that maximize public health gain are morally permissible, even morally obligatory. The rest of the chapter queries this naïve view by presenting constraints on the pursuit of maximal public health gain from within the consequentialist tradition to which it belongs. In other words, more sophisticated versions of utilitarianism rule out some public health activities, despite the health gains they can be expected to produce. Let’s start with some definitions of basic terms.
Defining consequentialism and utilitarianism
Consequentialism is a major moral theory that states that the moral value of an action is determined solely by consequences (Rachels and Rachels 2007: 89–116). ‘Action’ is here used as an umbrella term for whatever it is the morality of which is in question, which can include single acts, motives, policies, regulations, laws and public health interventions. Examples of the ‘moral value’ of an act include being right, wrong, permissible, obligatory and supererogatory. This all sounds rather technical, but a virtue of consequentialism – an odd word, but actually quite a helpful piece of academic jargon – is that it captures a very natural and familiar line of thought. All of us have been faced with a moral situation in which we are puzzled as to the right thing to do; consequentialism says, in such circumstances, look only to the consequences of the available actions. The right thing to do is that which will bring about the best consequences. The wrong thing to do is that which will fail to bring about the best consequences.
Left at this, consequentialism is not much use because, unless we explain what makes a set of consequences good, or better than others, the idea that one ought to bring about the best one is unhelpful. This is where utilitarianism comes in. Utilitarianism is the example, or version, of consequentialism that states that what makes a set of consequences good is that it maximizes ‘utility’. ‘Utility’ – a rather old-fashioned word – is often translated in terms of pleasure, happiness and, conversely, freedom from pain. But, since such terms make the theory sound hedonistic in a somewhat shallow sense, better phrases are well-being, welfare and benefit. So, utilitarianism is the version of consequentialism that says that the right action is that which brings about the best consequences, and the best consequences are those that maximize well-being, welfare or benefit.
Further clarifications
Before applying utilitarianism to public health, some further clarificatory remarks are called for in order to avoid misunderstandings. Firstly, utilitarianism is an impartial (or impersonal) theory. To explain, suppose someone were to ask whose welfare we are supposed to bother about, or whose well-being counts for most, when making a moral decision. The answer, according to utilitarianism, is that the well-being of everyone affected by the action in question counts and, moreover, counts equally. This is one of the most appealing aspects of utilitarianism: it is impartial (or impersonal) in the sense of denying that the welfare of some individual(s) or type(s) of people is more important than that of others. So, utilitarianism does not say that the right action is that which maximizes well-being for myself, or white people, or straight people or the able-bodied, or whomever; rather, it says that we should impartially maximize well-being.
To counter another possible misunderstanding, consider an imaginary scenario. A moral agent is walking quickly towards a class that is about to start. They see a frail, elderly person having difficulty crossing a busy road. The agent decides to stop, risking missing the start of their class in order to help. Halfway across, and without any warning, a drunken driver comes careering down the road, heading straight for them. The agent manages to dive out of the way but the elderly person is hit and injured. Did the agent do the morally right thing, according to utilitarianism? Referring to what might be called classical utilitarianism, the answer is, no, because utilitarianism says that the right action is that which maximizes benefit and, in this case, benefit was not maximized. But this might seem counter-intuitive. Here, it is useful to distinguish acting so as to maximize actual benefit and acting so as to maximize expected benefit, in order to suggest that we ought to act so as to maximize expected, not actual, utility. In helping the elderly person across the road the agent had every reason to expect to provide benefit (a safe passage) at a small cost (being late for class). So, according to this, arguably more intuitive, utilitarian account, the agent did the morally right thing, despite the actual, unfortunate outcome of their action.
Another point can cause confusion. Many people associate utilitarianism with the phrase, ‘the greatest good for the greatest number’. To explain the misunderstanding that can arise here, consider another, rather more fanciful scenario. Imagine that a moral agent possesses the last 5 ml of a drug. What makes the drug unusual is that if 1 ml of it is given to each of five people, it has the effect of curing their common colds quite quickly, but if all 5 ml of the drug is given to one person who has a certain life-threatening condition, it has the effect of saving their life. Which should the agent do according to utilitarianism: give 1 ml to each of the five people, or all 5 ml to the one person? A natural line of thought is that, to do the greatest good for the greatest number, the agent should give 1 ml to each of the five people, because that way they help more people. But this is not correct. The utilitarian is interested in maximizing benefit per se, rather than maximizing the number of people who get some benefit from one’s actions: i.e., it is about the greatest good, not the greatest number. So, because saving a person’s life is of immeasurably greater benefit than getting over a cold a bit quicker, the utilitarian would conclude that the right action is to give all 5 ml to the one person.
The idea that the right thing to do is to maximize well-being is known as the principle of utility, and the weighing up of the expected utility of actions is called the utilitarian calculation. One might well complain that it is unrealistic of the utilitarian to expect us to do a utilitarian calculation every time we have to do something. Often, we simply do not have the time, energy or information to do so; and this might seem to imply that most of us are, for the most part, acting immorally. This is part of a general ‘over-demandingness’ objection to utilitarianism that we revisit in chapter 9, in the context of a discussion about whether there is a general duty not to infect others. But, in the present context, suffice to say that the utilitarian can recognize the role of what are called ‘rules of thumb’ in moral deliberations. Take the example of turning up to work on time. Do we really need, every day, to calculate that being punctual maximizes expected utility? It is easy to notice that, generally speaking, being late for work causes problems to patients, colleagues and even ourselves that can be avoided simply by being on time. Given this, we should act according to the rule of thumb, I ought to get to work on time, rather than having to recalculate the same moral equation and getting the same result over and over again. The point to note is that this is still utilitarianism because what makes it right to act according to such a rule of thumb is that, in our experience, doing so tends to maximize well-being.
There are numerous objections to utilitarianism, debate about which is a massive industry in moral philosophy (Rachels and Rachels 2007). There is not space to go deeply into this, which is not central to our concerns. But, to give a flavour of the discussion, recall the point made above about impartiality: utilitarianism aims at benefit, so it does not endorse preference for, or prejudice against, individuals or even types of people. This is said to be a virtue of the theory, but it is also a source of criticism. In one respect, this is another example of the general over-demandingness objection to utilitarianism just mentioned. But the more pertinent objection here is that utilitarianism must be a false theory because it is at odds with some of our strongest moral intuitions. For example, people value their children’s welfare much more highly than that of strangers, and it is not clear that to do so is to be immoral (this phenomenon is known as ‘agent-relativity’). Utilitarians devise ways around the problem. One involves the notion of ‘satisficing utilitarianism’, which replaces the idea that the right action is that which maximizes benefit with the idea that an action is (all) right provided that it produces a satisfactory amount of benefit (Slote and Pettit 1984; Bradley 2006). This leaves open the possibility of being a utilitarian whilst preferring to benefit one’s nearest and dearest: so long as the agent has acted so as to produce enough benefit given the circumstances, they can prioritize their loved ones even if they could have produced more overall utility by being wholly impartial. These are the kinds of debates in moral philosophy about utilitarianism, but rather than dwell on them further let’s focus on applying utilitarianism to public health.
The naïve utilitarian view of public health
Public health, in spirit, principle and practice, is a utilitarian endeavour: ‘Although public health measures have been undertaken for centuries, the philosophical basis of modern public health is generally considered to be nineteenth century utilitarianism’ (Rothstein 2004: 176). The whole impetus behind public health is utilitarian. As Horner (2000: 49) puts it: ‘Public health is basically utilitarian in character’; and furthermore: ‘For public-health professionals, this perspective has a strong intuitive appeal’ (Roberts and Reich 2002: 1055). After all, the aim of public health is to benefit populations of people by protecting and promoting their health status. So, a simple formula suggests itself: utilitarianism says that the morally right thing to do is to maximize benefit; health is a benefit; therefore, any public health policy that will produce maximal health gain is morally justified (even obligatory). It seems that the problematic of this book – i.e., the justification for public health interventions – is not so problematic after all: a public health intervention is justified on the utilitarian grounds that it maximizes utility. Why not just leave it there?
Initial objections to the naïve view
Even if we stick with utilitarianism as introduced so far in this chapter, there is a very straightforward problem with this formula. One of the most basic objections to utilitarianism is that it is often very difficult to compare the utility values of dissimilar outcomes. Suppose, for example, £10,000 is given to a group of my students who are told to spend it so as to maximize utility. Various spending plans would be suggested: some want to go travelling, some want better academic resources, most want a very big party. All these plans produce similar amounts of benefit, but benefit of different, apparently incomparable kinds. How are we to decide which is the right thing to do with the money? Putting this in public health terms, utilitarianism has problems adjudicating between alternative public health policies that would create similar amounts of different kinds of health benefits.
This problem often arises because of scarce resources. Katz and Peberdy (1997: 93–4) have a nice example of a community health worker who only has resources sufficient for one of two projects, namely, setting up a playgroup or developing a service to counsel five individuals on their diet. According to utilitarianism, which should they do? They should maximize expected health benefit. But similar amounts of benefit would accrue from the two options. So the question becomes, which is the most important or valuable kind of health benefit, the mental health of parents and the physical and emotional health of children to be gained from the playgroup, or the reduced risk of heart diseases and other illnesses due to the improved diet of the recipients of counselling? The same question arises in the current Covid-19 pandemic. Which policy responses to the crisis are justified? Applying utilitarianism, the answer is, those responses that maximize utility. But different policies create different kinds of health benefits. For examples, lockdowns are effective in reducing transmission of the disease; but keeping schools open is very good for children’s mental health. Utilitarianism, as presented so far, seems unable to determine which of these competing policies is the right one.
Perhaps such trade-offs are not so difficult. After all, in such cases, whichever option is chosen, a good deal of utility in the form of health benefits has been created, albeit health benefits of different sorts. If neither option is the winner in the sense of obviously creating more health benefit, either is justified on utilitarian grounds (recall the notion of ‘satisficing utilitarianism’ from above). Also, the utilitarian can respond by saying that these kinds of problems are not very deep. In other words, there may well be difficulties in quite how to do the utilitarian calculation when different sorts of health benefits are on offer, but the fundamental idea in ‘naïve utilitarianism’ – i.e., a public health intervention that maximizes utility in the form of health – is intact.
So, let’s change tack and look at some other considerations counting against naïve utilitarianism about public health. To recall the simple formula mentioned a moment ago: the right thing to do is to maximize benefit; therefore, since health is a benefit, any public health policy that maximizes health gain is justified. This seems to suggest that even very Draconian public health measures are justifiable. For example, smoking is a public health problem, and there are enormous health benefits to be gained by eradicating smoking. So why not go the whole hog and ban cigarette production, outlaw smoking, refuse to treat smoking-related diseases, even publicly shoot a small number of smokers to deter the recalcitrant? Obviously, at least some of these policy initiatives are unethical. But why? Where do the constraints on the pursuit of utility in the form of maximal health benefits come from? As outlined in the Introduction to part I, the key is to distinguish various kinds of constraints: the first kind stays within the consequentialist tradition, and we deal with those in the rest of this chapter; the next chapter looks at constraints on the pursuit of health from non-consequentialist ethical traditions.
Better consequentialist rejoinders to the naïve view
The first point to note is that, in the brief outline of naïve utilitarianism sketched so far in this chapter, we have said very little about the nature of consequences of actions. But when we reflect more on this, some salient points emerge. The first is that there is a tendency to think in terms of immediate or short-term consequences. But this is very unsophisticated. Consequences ramify; in fact, one of the most disconcerting features of moral life is that one’s actions can initiate sequences of consequences that go far beyond the immediate. So it is with public health policy. Lockdowns in response to Covid-19 are a case in point. As just mentioned, lockdowns are effective in reducing transmission of the disease, so the immediate or short-term consequences of locking societies down are very good. But one of the main objections to lockdowns is that they store up very bad consequences in the long term. These include health consequences – cancers and other serious conditions went undiagnosed due to lockdown, for example – and non-health examples, such as the deleterious effect on children’s education. The point is that short-term effects achieved by a policy have to be offset against, and might even be outweighed by, long-term consequences.
A second salient point is that there is a tendency to restrict our view of consequences to those of a certain type. In particular, in the present context, it is tempting to think only in terms of health-related consequences. But utilitarianism is not a theory specifically about, let alone restricted to, health and medicine. What matters in utilitarianism is utility per se, not utility of a particular type, so health benefits are only as important as other kinds of benefit: ‘Health is important as a component of well-being [but] on any sensible view of [health and well-being] people trade off health against other goods’ (Wilkinson 2009: 245). Given this, a utilitarian would object to a policy that fails to maximize benefit in general, even if it maximizes health benefit in particular. A current example is the introduction of Covid-19 vaccine passports – i.e., documentary evidence of having been vaccinated against Covid-19, as a condition of access to certain events or venues, or of being allowed to travel or return to work – that were alluded to in the Introduction. Suppose such a scheme would have major health benefits in terms of avoiding transmission of the virus. Nonetheless, a utilitarian might still object, on non-health-related grounds, such as that the scheme has the non-health-related effect of increasing inequity or stigmatizing some sectors of society (Voo et al. 2020). In sum, it might be that the result of a utilitarian calculation restricted to health consequences is in favour of a policy, but a utilitarian calculation that includes all consequences – health-related and others – is not.
Rule-utilitarianism
So far, we have considered two consequentialist grounds for constraints on naïve utilitarianism about public health policies: building long-term consequences, and costs and benefits other than health-related ones, into the utilitarian calculation. There is a third point that is somewhat more far-reaching, because it requires distinguishing between what are traditionally regarded as the two main versions of utilitarianism, namely, act-utilitarianism (or direct utilitarianism) – which is the version we have been working with so far – and rule-utilitarianism. To explain, consider a classic thought experiment (McCloskey 1965; cf. Smart and Williams 1973). Imagine a deeply racist town divided between an affluent white community and their poor black neighbours. Relations between the two have degenerated into mutual hostility and suspicion. A truly heinous crime has been committed against a member of the white community, which is outraged and convinced of the culpability of a particular black person. The town’s sheriff has information that shows the suspect to be innocent, but which would not persuade the mob. If the sheriff were to publicly hang the suspect, the white community would be appeased. Otherwise, they will go on the rampage and commit terrible atrocities. According to utilitarianism, what ought the sheriff do?
Utilitarianism seems to be in trouble here because it appears that the sheriff maximizes utility by hanging an innocent man, which is obviously immoral, so utilitarianism must be a false theory. The utilitarian can appeal to the kinds of points already made in this chapter. To apply the point about long-term ramifications of one’s actions, the public hanging would maximize utility in the short term, but what are the long-term consequences of this kind of expediency? What are the subtle effects on the integrity of the legislature? What would be the effects on this society if the expediency were discovered? Conversely, what long-term utility, in terms of setting an example of honesty and integrity, is lost by avoiding the high short-term cost of a riot, and going ahead with the hanging? But such complications can be factored out. This is a thought experiment, so we can change the conditions to get at the salient points any way we like. So, let’s stipulate that the expedient nature of the hanging is never discovered; the riot would be unspeakably awful; the suspect, though innocent of this crime, was guilty of some other, and, if released, would go on to do terrible things, and so on.
Manipulating the thought experiment in such ways makes it untenable that utilitarianism, as understood so far, concords with our ethical intuitions. This motivates rule-utilitarianism. The key to rule-utilitarianism is the distinction between acts and rules. As mentioned above, ‘acts’ means individual actions, motives, policies, etc. But the rules invoked in rule-utilitarianism are those sanctioned because utility is maximized by society accepting and following them. So, according to the version of utilitarianism we have been dealing with so far, the focus is on the act (hence, ‘act-utilitarianism’) and the moral value of the action is evaluated directly in terms of its consequences (hence, ‘direct utilitarianism’). But, according to the alternative version, i.e., rule-utilitarianism, the moral value of an act depends on whether it accords with rules. Two points are important here: first, this alternative is still a version of utilitarianism, because which societal rules are sanctioned depends solely on whether abiding by them maximizes benefit; and, second, this is ‘indirect utilitarianism’, in the sense that the act in question is not evaluated directly by reference to its consequences, but indirectly by asking whether it accords with the rules (Hooker et al. 2000).
The rule-utilitarian can deal with the thought experiment about hanging the innocent suspect. The question for the rule-utilitarian is not about the direct consequences of that act itself. Rather, the question is, does the relevant action accord with rules sanctioned by society because they maximize utility? Clearly, the answer is no. Consider two candidates for part of the set of societal rules: punish according to guilt versus punish according to expediency. Clearly, it is the former, and not the latter, which would form part of a set of rules sanctioned and followed because doing so maximizes utility. So, for the sheriff to hang the innocent suspect would not be in accord with the relevant rules. Therefore, it is wrong on rule-utilitarian grounds.
The crucial thing is that act- and rule-utilitarianism can come apart in this way when evaluating public health policies. Savulescu et al. (2020) give a nice example. One of the most distressing challenges of the Covid-19 pandemic was triage, i.e., which Covid patients should have access to ventilators, given that there were too few for everyone. Applying act-utilitarianism, the decision would be made by asking who would benefit most, because this would maximize utility. Typically, this means that younger, healthier patients should be ventilated because they stand to benefit more than older, less healthy or disabled patients. But applying rule-utilitarianism might give a different result. Prioritizing younger, healthier patients is discriminatory. And anti-discrimination rules (enshrined in law) exist because abiding by them maximizes utility overall. So, according to rule-utilitarianism it would be wrong to discriminate between younger, healthier patients, and older, less healthy or disabled patients, when deciding who to ventilate. The way act- and rule-utilitarianism have come apart in this case is very common in public health, because specific public health policies can often be related to general rules, typically enshrined in law, governing the activity in question. So naïve utilitarianism about a public health initiative is very frequently challenged by appeals to rule-utilitarianism.
Concluding remarks
This chapter has introduced and clarified the moral theory at the heart of public health, namely, utilitarianism. The naïve utilitarian view of public health was presented. Three kinds of constraints on naïve utilitarianism about public health, all from within the consequentialist perspective, were delineated and illustrated. The first two constraints are discernible within act-utilitarianism; the third consisted of shifting from act to rule-utilitarianism. We can extrapolate from this to a general strategy for analysing any public health intervention. Any viable public health policy or programme is proposed because it will produce utility in the form of public health. The three kinds of consequentialist questions raised in this chapter can be asked of it. First, what are the long-term ramifications of implementing that policy? Second, are there goods and values other than health that will be achieved by implementing or refusing to implement the policy in question? Third, even if the policy in question seems sound on act-utilitarian grounds, how does it look according to rule-utilitarianism?
2Non-consequentialism
CONSEQUENTIALIST constraints of the kind outlined in the previous chapter are not the only resources within moral philosophy with which to resist the naïve utilitarian view of public health. Staying within moral philosophy, but moving outside consequentialism, there are plausible non-consequentialist moral theories that ground such resistance. This chapter introduces three non-consequentialist theories that can be adapted to inform public health ethics, namely, deontology, virtue ethics and principlism.
Deontology
Deontology appeals to a line of thought about ethics that is as natural and familiar as, but contrasts sharply with, consequentialism. The difference between these two moral theories lies in what they claim is the source of moral value. Consequentialism claims that moral value is determined solely by consequences; i.e., whether an action is right, wrong, obligatory, etc., is traced directly or indirectly to its consequences. By contrast, deontology claims that moral value can be independent of consequences. Specifically, the moral value of an action can depend on the nature of the action itself. Correspondingly, according to deontology, ethically speaking, some actions must be performed, and others must not, irrespective of any consequences. Given this, we can now make some sense of the strange word ‘deontology’, which is derived from an ancient Greek phrase that literally means the study of what is necessary, but is usually translated in terms of duty or what one must do (Rachels and Rachels 2007: 117–40).
Deontology is appealing because duty is such an obviously ethical notion. That some actions must be performed or avoided, and that one must fulfil this out of moral duty and irrespective of the outcome, are ideas basic to both deontological ethics and ordinary moral thinking. There is a pitfall here. It is tempting to infer from this emphasis on duty that deontology is the really ethical theory, the one that is really about morality, as opposed to a consequentialist theory such as utilitarianism which, by contrast, seems rather pragmatic and expedient. This is a mistake because both deontology and consequentialism are, equally, theories about ethics and morality, the difference between them being in what they say makes an action right or wrong. According to deontology, an action can be ethical or unethical because of its very nature; by contrast, according to consequentialism, an action’s moral value is never determined by the nature of the action itself, but by reference to consequences. There is a clear difference here, but not between a theory (deontology) that is about morality versus another (consequentialism) that is not.
It is worth pausing to illustrate this distinction between consequentialism and deontology. As is well known, Jehovah’s Witnesses refuse to consent to blood transfusions. Imagine a clear-cut case in which a Jehovah’s Witness is in dire need of a transfusion without which they will become very ill and die. How would a utilitarian approach the case? As the discussion in the previous chapter indicates, this is more complicated than might at first appear, because it depends on what version of utilitarianism is in play (recall the more sophisticated versions of act-utilitarianism, and rule-utilitarianism, from chapter 1). Nonetheless, whatever version of the theory one subscribes to, according to consequentialism, the moral value of the various available actions traces back to consequences. But to the Jehovah’s Witness patient, the blood transfusion is an action which, in itself and by its very nature, is ethically impermissible. Consequences are simply irrelevant to their moral evaluation. So, when the utilitarian health professional explains to the patient that the consequences of refusing the transfusion are that their painful, life-threatening condition will worsen, they get the deontological response that, nonetheless, religious duty precludes consenting to the treatment.
A worry people often have about this illustration is that the Jehovah’s Witness is in fact behaving like a consequentialist. On this account of the case, they are motivated to resist the blood transfusion because in so doing they increase the chances of their enjoying good consequences, such as getting to heaven, and avoid bad consequences, such as incurring God’s displeasure. If this is the correct construal of the case, and the patient really is a consequentialist who is basing their action solely on its anticipated outcome, then it is not a useful illustration of deontology and should be abandoned for a better one. (Note, though, that it still would not be a case of utilitarian thinking: as explained above, utilitarianism is the impartial moral theory that an action is right in so far as it maximizes utility whereas, on this account, the patient is acting so as to ensure the best spiritual outcome for themselves.) But this consequentialist account does not seem like the right way to interpret the action. A devotee does not think in such a calculative manner but, rather, acts dutifully in accordance with religious proscriptions. This is why the patient would be offended by the thought that they refuse consent in order to curry favour with God or increase their chances of getting to heaven. For them, it is simply their duty to refuse the treatment because a blood transfusion is the sort of action which is, by its nature, wrong.
Kantianism
As was the case with consequentialism, deontology per se is not much use because there is little point in being told that moral value depends on the nature of the action in question until something is said about the kinds of actions that, by their very nature, are right or wrong. Again, the example of the Jehovah’s Witness patient is instructive. Most of us are not Jehovah’s Witnesses; and of those of us who are not, some subscribe to different but equally strongly held religious convictions, whilst others are non-religious. So, to avoid letting deontological ethics degenerate into a series of stand-offs between people who ascribe moral value on the basis of the nature of actions differently, we need an account of what
