Paternalistic interventions restrict individuals’ liberty or autonomy so as to guide their decisions towards options that are more beneficial for them than the ones they would choose in the absence of such interventions. Although some philosophers have emphasised that there is a case for justifiable paternalism in certain circumstances, much of contemporary moral and political philosophy works from a strong presumption against paternalistic interventions. However, Richard Arneson has argued that there are egalitarian reasons that support the case for paternalism: paternalistic (...) interventions can protect poor decision-makers from making ‘bad’ choices, thus preventing inequalities between them and those with better decision-making skills. This paper seeks to clarify and advance our understanding of the egalitarian argument for paternalism. Arneson’s argument adds an important and often neglected dimension to the debate about paternalism but also raises a number of questions about equality, paternalism and the relationship between the two. (shrink)

This paper scrutinizes the tension between individuals’ rights and paternalism. I will argue that no normative account that includes rights of individuals can justify hard paternalism since the infringement of a right can only be justified with the right or interest of another person, which is never the case in hard paternalism. Justifications of hard paternalistic actions generally include a deviation from the very idea of having rights. The paper first introduces Tom Beauchamp as the most famous contemporary hard paternalist (...) by outlining his moral theory (principlism) and showing why it, as it stands, has to allow for hard paternalism. Secondly, the paper focuses on the notion of rights within principlism. I will employ traditional theories of rights to make sense of rights in principlism. Unfortunately, this attempt fails. In the third part, then, I claim that rights can only be limited with reference to the rights or interests of others. This structure is the very point of rights, it is their bite. I will argue for this claim and show its implications. The most important implication is that not only principlism, but every normative theory that includes rights of individuals, has to abolish hard paternalism. (shrink)

Experimental vaccines are being developed for the treatment of ‘unhealthy lifestyles’ and associated chronic illnesses. Policymakers and other stakeholders will have to deal with the ethical issues that this innovation path raises: are there morally justified reasons to integrate these innovative biotechnologies in future health policies? Should public money be invested in further research? Focusing on the case of an experimental nicotine vaccine, this article explores the ethical aspects of ‘lifestyle vaccines’ for public health. Based on findings from a qualitative (...) study into a vaccine for smoking cessation, the article articulates possible value conflicts related to nicotine vaccination as an intervention in tobacco control. The ‘vaccinization’ of lifestyle disease piggybacks on the achievements of classic vaccines. Contrary to expectations of simplicity and success, quitting smoking with a vaccine requires a complex supportive network. Social justice and public trust may become important ethical challenges when deciding whether to use further public funds for research or whether to implement these innovative vaccines in the future. (shrink)

The ethics of health incentive research—a form of public health research—are not well developed, and concerns of justice have been least examined. In this paper, we explore what potential long term harms in relation to justice may occur as a result of such research and whether they should be considered as part of its ethical evaluation. ‘Long term harms’ are defined as harms that contribute to existing systematic patterns of disadvantage for groups. Their effects are experienced on a long term (...) basis, persisting even once an incentive research project ends. We will first establish that three categories of such harms potentially arise as a result of health incentive interventions. We then argue that the risk of these harms also constitutes a morally relevant consideration for health incentive research and suggest who may be responsible for assessing and mitigating these risks. We propose that responsibility should be assigned on the basis of who initiates health incentive research projects. Finally, we briefly describe possible strategies to prevent or mitigate the risk of long term harms to members of disadvantaged groups, which can be employed during the design, conduct and dissemination of research projects. (shrink)

Recent articles published in this journal have highlighted the shortcomings of individualistic approaches to health promotion, and the potential contributions of relational analyses of autonomy to public health ethics. I argue that the latter helps to elucidate the former, by showing that an inadequate analysis of autonomy leads to misassignment of both forward-looking and backward-looking responsibility for health outcomes. Health promotion programmes predicated on such inadequate analyses are then ineffective, because they assign responsibility to agents whose social environment inhibits their (...) ability to act on such responsibilities; inequitable, because the social barriers to autonomous agency display a socio-economic gradient; and stigmatizing, because they license blaming of individuals for their own poor health without taking into account how reasonable it is to hold these individuals responsible, given the social barriers to autonomy they face. I further sketch how incorporating a relational understanding of autonomy could help to produce health promotion programmes that do not succumb to these difficulties, while avoiding coercive paternalism, exploring potential applications in ecological approaches to health promotion. (shrink)

Incentive schemes, which offer recipients benefits if they meet particular requirements, are being used across the world to encourage healthier behaviours. From the perspective of equality, an important concern about such schemes is that since people often do not have equal opportunity to fulfil the stipulated conditions, incentives create opportunity for further unfair advantage. Are incentive schemes that are available only to disadvantaged groups less susceptible to such egalitarian concerns? While targeted schemes may at first glance seem well placed to (...) help improve outcomes among disadvantaged groups and thus reduce inequalities, I argue in this paper that they are susceptible to significant problems. At the same time, incentive schemes may be less problematic when they operate in ways that differ from the ‘standard’ incentive mechanism; I discuss three such mechanisms. (shrink)

While Powers and Faden do not consider possible anti-paternalism objections to their view, there are two variants of this objection that a social justice perspective is susceptible to. It is worth exploring which responses to such objections may be less promising than others. It is argued that for most public health measures targeting the disadvantaged, theorists and practitioners taking a social justice perspective should bite the paternalist bullet. Insofar as the government has the ability to reduce mortality and morbidity within (...) the population in a way that is fair and in everyone’s interests, then the use of paternalistic means or resultant paternalistic effects should be thought to be the lesser evil. (shrink)

Lifestyle-induced diseases are becoming a burden on healthcare, actualizing the discussion on health responsibilities. Using data from the National Association for Heart and Lung Diseases ’s 2015 Health Survey, this study examined the public’s attitudes towards personal and social health responsibility in a Norwegian population. The questionnaires covered self-reported health and lifestyle, attitudes towards personal responsibility and the authorities’ responsibility for promoting health, resource-prioritisation and socio-demographic characteristics. Block-wise multiple linear regression assessed the association between attitudes towards health responsibilities and individual (...) lifestyle, political orientation and health condition. We found a moderate support for social responsibility across political views. Respondents reporting unhealthier eating habits, smokers and physically inactive were less supportive of health promotion policies. The idea that individuals are responsible for taking care of their health was widely accepted as an abstract ideal. Yet, only a third of the respondents agreed with introducing higher co-payments for treatment of ‘self-inflicted’ conditions and levels of support were patterned by health-related behaviour and left-right political orientation. Our study suggests that a significant support for social responsibility does not exclude a strong support for personal health responsibility. However, conditional access to healthcare based on personal lifestyle is still controversial. (shrink)

Is it a stronger interference with people's freedom to withdraw options they currently have than to withhold similar options they do not have? Drawing on recent theorizing about sociopolitical freedom, this article identifies considerations that often make this the case for public policy. However, when applied to tobacco control, these considerations are shown to give us at best only very weak freedom-based reason to prioritize the status quo. This supports a popular argument for so-called “endgame” tobacco control measures: If we (...) believe that cigarettes would and should be withheld from entering markets in hypothetical scenarios in which they do not yet exist, then we also have reason to seek their abolition in situations, such as ours, in which cigarettes do exist—if necessary by banning their sale. The same considerations are then used to disarm objections that have recently been raised to using nudges in public policy. (shrink)

A growing body of empirical research examines the effects of the so-called “social determinants of health” on health and health inequalities. Several high-profile publications have issued policy recommendations to reduce health inequalities based on a specific interpretation of this empirical research as well as a set of normative assumptions. This article questions the framework defined by these assumptions by focusing on two issues: first, the normative judgments about the fairness of particular health inequalities; and second, the policy recommendations issued on (...) this basis. We argue that the normative underpinnings of the approach are insufficiently supported and that the policy recommendations do not necessarily follow from the arguments provided. Furthermore, while many of the policies recommended—such as improving people's living conditions and reducing inequalities in wealth and power—are justified in their own right, the way these recommendations are tied to health is problematic. (shrink)

What justifies differences in the acceptance of paternalism towards competent minors and older people? I propose two arguments. The first argument draws on the widely accepted view that paternalism is easier to justify the more good it promotes for the paternalizee. It argues that paternalism targeting young people generally promotes more good for the people interfered with than similar paternalism targeting older people. While promoting people's interests or well-being is essential to the justification of paternalism, the first argument has certain (...) unfair implications in that it disfavours paternalism towards the worse off. The second argument caters to such fairness concerns. It argues that priority or inequality aversion supports age-differentiated paternalism because young people, who act imprudently and thereby risk their interests or well-being, are worse off than older people who act in similar ways. I suggest that both arguments are pertinent in evaluating specific paternalistic acts and policies. (shrink)

Journal of Political Philosophy, EarlyView.

In this paper, I am going to explore some of the moral considerations relating to smoking licences. And I shall offer a limited defence of licences as a replacement for sales tax on tobacco products. This defence will include some moral arguments in favour of one particular licence design over others.

This article provides a survey of various topics in which questions about taxation feature alongside questions about justice. It seeks to argue mainly that taxation is a rather fragmentary domain of inquiry about which it is hard to envisage the development of views about what justice requires with respect to tax policy in general. Guided by this idea, the article attempts to highlight some aspects of taxation whose connection with justice has been under-explored by philosophers, as well as to acquaint (...) the reader with a sense of the more thoroughly researched areas. (shrink)

Lifelong smokers lose on average a decade of life vis-à-vis non-smokers. Globally, tobacco causes about 5–6 million deaths annually. One billion tobacco-related deaths are predicted for the 21st century, with about half occurring before the age of 70. In this paper, we consider a complete ban on the sale of cigarettes and find that such a ban, if effective, would be justified. As with many policy decisions, the argument for such a ban requires a weighing of the pros and cons (...) and how they impact on different individuals, both current and future. The weightiest factor supporting a ban, we argue, is the often substantial well-being losses many individuals suffer because of smoking. These harms, moreover, disproportionally affect the disadvantaged. The potential gains in well-being and equality, we argue, outweigh the limits a ban places on individuals’ freedom, its failure to respect some individuals’ autonomous choice and the likelihood that it may, in individual cases, reduce well-being. (shrink)

This article asserts that traditionally dominant models of health promotion in the US are fairly characterized by methodological individualism. This schema produces a focus on the individual as the node of intervention. Such emphasis results in a number of scientific and ethical problems. I identify three principal ethical deficiencies: first, the health promotions used are generally ineffective, which violates canons of distributive justice because scarce health resources are expended on interventions that are unlikely to produce health benefits. Second, the health (...) promotions used tend to expand health inequalities between the affluent and the least well-off. Third, the health promotions used are likely to intensify stigma against the least well-off, a deficiency that itself may exacerbate the ‘densely-woven patterns of disadvantage’ that characterize life on the tail of the social gradient. Because Powers and Faden’s health sufficiency model of social justice argues that the amelioration of such clusters of disadvantage should be the primary ethical goal of public health policy, methodologically individualist models of health promotion are ethically deficient and should not stand as primary approaches for health promotion in a just social order. (shrink)

There is a large literature exploring the concept of ‘health promotion’. However, the meaning of the term remains unclear and contested. This is for at least two reasons. First, any definition of ‘health promotion’ is going to have to outline and defend an account of the notoriously controversial concept of ‘health’, and then suggest how (and why) we should promote it. Second, health promotion clearly has some overlap with ‘public health’, but it is far from clear how they are related. (...) Is health promotion part of public health or is health promotion a radically different type of activity from public health? Answering this question requires engaging with tricky professional as well as contentious conceptual issues. Some advocates of health promotion talk as though public health is problematic: seen as medical, physiological in focus and reductionist in approach, whereas health promotion, on this view, is focused on the whole person in a social environment. However, to an outsider this looks more like an attempt to artificially (and rather crudely) define and protect professional boundaries, rather than a contribution to conceptual analysis. There seems no good reason why public health cannot take into account the role of social, political, economic and cultural factors and their impact on health. Indeed, much work in public health does precisely this, and uses a wide range of methodologies drawn from non-medical disciplines such as geography, sociology and psychology, not just epidemiology. It seems much more sensible to see health promotion as being one vitally important aspect of the work of public health, rather than something markedly distinct. We will assume here that this is the case and focus instead on the first issue: what is health promotion? (shrink)

In this paper I provide a critique of a set of assumptions relating to agency, choice and the legitimacy of actions impacting health that can be seen in some approaches to health promotion. After a brief discussion about the definition of health promotion, I outline two contrasting approaches to this area of health care practice. The first is focused on the provision of information and the second is concerned with seeking to change people’s preferences in a particular way. It has (...) been argued by a number of critics of health promotion that only the first approach is ethical, as it is for individuals to make their own lifestyle choices and adopt their own conception of the good life. I argue against this ‘information’ approach to health promotion on two grounds. First, I suggest that given the aims of health promotion, the provision of information is, as a matter of fact, of limited effectiveness in achieving these aims. Second, I argue that we have good reasons to question the appropriateness of respecting many of the preferences that individuals happen to have, given the origins and quality of such preferences. I then go on to argue, that by contrast we have good reasons to focus on changing at least some of the preferences that people have related to their lifestyle choices. This involves a commitment to both paternalism and a defence of a certain conception of the good life, but both can be defended. I use the example of potential responses to the growing problem of obesity to illustrate my argument, arguing that only policy that, at least sometimes, aims at preference change will be both effective and ethical. (shrink)

Considerations of objective-value freedom and status freedom do impose constraints on policies that restrict access to cigarettes. As to the objective-value freedom, something of value is lost when anti-alcohol policies lead to pub closures interfering with valued life styles, and a similar, though weaker, argument can be made for cigarettes. As to status freedom, non-arbitrariness requires consultation with vulnerable populations to learn what might aid them with smoking cessation.

The majority of deaths due to tobacco in the twenty-first century will occur in the developing world, where over 80% of current tobacco users live. In November 2010 guidelines were adopted for implementing Article 14 of the World Health Organization’s Framework Convention on Tobacco Control (FCTC). The guidelines call on all countries to promote tobacco treatment programs. Nevertheless, some experts argue for a strict focus, at least in developing countries, on population-based measures such as taxes and indoor air laws, which (...) they consider more cost-effective than individual treatment. In this article we defend tobacco dependence treatment in developing countries. First, these experts understate the comparative cost-effectiveness of individual treatment programs. Second, they overlook numerous ethical considerations beyond cost-effectiveness that support individual tobacco treatment in developing countries. We conclude that the strict population-based focus in developing country tobacco control advocated by some experts is misplaced. In general, developing nations should combine population-based measures and individual tobacco treatment programs. (shrink)

The use of tanning beds has been identified as being among the most significant causes of melanoma and non-melanoma skin cancer. Accordingly, the activity is properly seen as one that involves profound harm to self. The article examines paternalistic reasons for restricting sunbed usage. We argue that both so-called soft and hard paternalistic arguments support prohibiting the use of sunbeds. We make the following three arguments: an argument from oppressive patterns of socialization suggesting that the autonomous nature of the conduct (...) in question is questionable; an argument from so-called evaluative delusions in which individuals attach incorrect weights to some of their values; a strictly hard paternalistic argument appealing to the harm in itself pertaining to the use of sunbeds. (shrink)

People’s health is hugely affected by where they live, their occupational status and their socio-economic position. It has been widely argued that the presence of such social determinants in health provides good reasons to reject luck egalitarianism as a theory of distributive justice in health. The literature provides different reasons why this responsibility-sensitive theory of distributive justice should not be applied to health. The critiques submit that the social circumstances undermine or remove people’s responsibility for their health; responsibility sensitive health (...) policies would adversely affect those who are worst off and; the luck egalitarian approach to health distracts from the important task of rectifying socio-economic influences on people's health and provides individualistic solutions to collective problems. But for each of these variants of the critique luck egalitarianism provides suitable answers. The literature on social determinants is no detriment to the project of applying luck egalitarianism to health. (shrink)

The exposure of doctors, nurses and other medical professionals to risks in the context of epidemics is significant. While traditional medical ethics offers the thought that these dangers may limit the extent to which a duty to care is applicable in such situations, it has less to say about what we might owe to medical professionals who are disadvantaged in these contexts. Luck egalitarianism, a responsibility-sensitive theory of distributive justice, appears to fare particularly badly in that regard. If we want (...) to maintain that medical professionals are responsible for their decisions to help, cure and care for the vulnerable, luck egalitarianism seems to imply that their claim of justice to medical attention in case of infection is weak or non-existent. The article demonstrates how a recent interpretation of luck egalitarianism offers a solution to this problem. Redefining luck egalitarianism as concerned with responsibility for creating disadvantages, rather than for incurring disadvantage as such, makes it possible to maintain that medical professionals are responsible for their choices and that those infected because of their choice to help fight epidemics have a full claim of justice to medical attention. (shrink)

This chapter concerns the normativity of the concepts of paternalism and libertarian paternalism. The first concept is central in evaluating public health policy, but its meaning is controversial. The second concept is equally controversial and has received much attention recently. It may or may not shape the future evaluation of public health policy. In order to facilitate honest and fruitful debate, I consider three approaches to these concepts, in terms of their normativity. Concepts, I claim, may be considered nonnormative, normatively (...) charged, or normative in that they involve more complex relationships between values or duties. While the last approach is often best, other approaches may be appropriate depending on the context and purpose of discussion. The chapter’s conceptual investigation is illustrated by application to two public health policies: a tax on the consumption of fat and the encouragement of health-promoting food displays in restaurants and supermarkets. (shrink)