The Goals of Public Health and the Ethics of Public Health Policy

1. The Goals of Public Health and the Ethics of Public Health Policy Christian Munthe Department of Philosophy, Göteborg University EuroPHEN, financed by the European Commission.

2. Traditional Goal, Restrictions & Problems • Goals • Promotion of the health of the population • Aggregate of the health status of individuals • Life-expectancy, mortality, morbidity, well-being • Focus on socio-economic policy as a means • What aggregate? (utilitarian, communitarian, weighing goods) • What population? (national vs. european vs. global) • Restrictions • Efficiency • Cost-benefit • Liberty/autonomy to a limited extent • Public Health vs. Medical Ethics • Population perspective vs. Individualist perspective (Doctor - patient relationship) • Respect for autonomy

3. Recent Trends • Equality • Focus on health inequalities • Empowerment of “weak” groups • Prioritarianism rather than strict egalitarianism (?) • Opportunities rather than actual health states • Conflict 1: poor uptake, inefficiency (traditional goal) • Conflict 2: unhealthy choices in spite of health opportunities • Autonomy • Focus on opportunity, access, information, empowerment • Focus on respecting choice ==> individual responsibility • Conflict 1 (surface): individual freedom vs. common good • Conflict 2 (deeper): individualist vs. population approach

4. A Population Approach to Autonomy(?) • The Autonomy ‘of the Population’ • Aggregate of individual autonomy (of what? How? Quantifiability?) • Strong communitarianism ==> organic theory of society ==> conflict with traditional goal more severe • Marriage of Equality and Autonomy • The equal opportunity of each member of the population to (autonomously) choose good/better health • Netherlands, Sweden, ?? • Promote the existence of real options for everyone to be more healthy (if they want to) • Focus on public goods, empowerment, information and choice • Particular individuals’ freedom to make unhealthy choices may be restricted (smoking in public places, restricting the content of X in food, etc.) • Restriction on the traditional goal • Prioritarianist emphasis • Only autonomy may trump autonomy

5. Justification and Application • Libertarian egalitarianism (moral claim) • Autonomy and equality are the primary values • Levelling down problem ==> traditional goal must play a part • Priority of Liberty (Rawls) • When a sufficient level of health is secured for everyone, ability to control one’s own health level becomes a priority (moral/psychological claim) • Utilitarianism (empirical claims) • The better off people are, the more they care about autonomy and equality • When a certain level of well being is secured, the connection between health and well being becomes more complex (Mill’s principle of first person priority + priority of liberty apply) • Suboptimal outcomes acceptable if they contribute to an optimal body of policies • Consequentialist prioritarianism • Increasing the well being of the worse off is more important (moral claim) • The utilitarian empirical claims • Applications to policy making • Expansion less appropriate, the worse the socio-economic setting • Threats to basic public goods justify retreat to traditional goal • Different goals appropriate in different social settings, nations, etc.