Public Health Ethics and Liberalism

Abstract This paper defends a distinctly liberal approach to public health ethics and replies to possible objections. In particular, I look at a set of recent proposals aiming to revise and expand liberalism in light of public health's rationale and epidemiological findings. I argue that they fail to provide a sociologically informed version of liberalism. Instead, they rest on an implicit normative premise about the value of health, which I show to be invalid. I then make explicit the unobvious, republican background of these proposals. Finally, I expand on the liberal understanding of freedom as non-interference and show its advantages over the republican alternative of freedom as non-domination within the context of public health. The views of freedom I discuss in the paper do not overlap with the classical distinction between negative and positive freedom. In addition, my account differentiates the concepts of freedom and autonomy and does not rule out substantive accounts of the latter. Nor does it confine political liberalism to an essentially procedural form. Introduction The establishment of public health ethics as a discipline in its own right seems innately related to questioning the suitability of a liberal framework (Dawson and Verweij, 2007: 8). For instance, it is often argued that although liberal approaches are congenial to bioethics and its focus on individual choices and patients’ autonomy, liberalism lacks the conceptual tools necessary to tackle the intricacies of public health ethics such as an irreducible concept of public good that a republican or communitarian strategy would be able to offer (Nuffield Council on Bioethics, 2007; Jennings, 2007a, b). Essentially, these proposals contend that if epidemiological findings are taken into proper consideration, liberalism should make room for public health interventions that go beyond standard constraints such as respect for basic liberties and individual choices, the harm principle and the conception of freedom as non-interference. In this paper, I will argue that these attempts to establish public health ethics on essentially revised liberal grounds are misconceived. My strategy will be as follows. In the opening section, I provide a logical reconstruction of a cluster of views whose constitutive feature is this apparent dissatisfaction with liberalism in public health ethics. The objective is to make explicit an underlying argument that could animate these views and to relate it to broader, initially appealing criticisms against liberalism. I then outline its continuity with some prima facie reasons for preferring a republican alternative. In subsequent sections, I critically examine what appear to be the two key premises of the reconstructed argument. The first is normative. It takes health to be an overarching value. The second comprises specific interpretations of epidemiological evidence that presumably expose liberalism as a sociologically naïve approach to public health. The thrust of my analysis in these sections is twofold. First, it purports to show that the prior, normative premise should be rejected because it derives from conflating prudential and moral reasons for valuing health and fails to respect its complex axiological structure. Second, it aims to demonstrate that the posterior, presumably empirical premise builds upon the invalid assumption that health is an overarching value. Hence, this premise cannot be used to support increasingly prescriptive policies as informed extensions of a liberal commitment to public health. This latter point indicates that such proposals effectively disengage with central liberal values and should be conceived as part of a different, republican project. In the final section, I reply to the challenges against liberalism outlined at the beginning of the paper and demonstrate its superiority over the republican alternative in the context of public health. In light of this analysis, I conclude that the liberal commitment to the value of toleration should be paramount within public health ethics. A major advantage of the proposed strategy consists in its capacity to both explain the popularity of recurrent criticisms against liberalism in public health ethics and show that these concerns are unfounded. Here, ‘liberalism’ stands primarily for procedural, e.g., Rawlsian liberalism. The rationale is that this strand relies more heavily on the conception of freedom as non-interference and invites a narrower understanding of the harm principle than perfectionist theories, which commit to additional values, such as autonomy. However, freedom as non-interference and a restrictive harm principle seem to be the main target of the criticisms mentioned above. In particular, they both are deemed incongruous with standard definitions of public health, which include collective initiatives in the pursuit of irreducibly public goals (Verweij and Dawson, 2007). Thus, my defence of liberalism will focus on these challenged features and aim to deal with ensuing criticisms on their own terms. Nevertheless, it directly applies to more substantive forms of liberalism as long as they intend to eliminate abusive conditions of choice rather than discount some choices as non-autonomous by default (Scanlon, 1988). Joseph Raz's Morality of Freedom is an example of such a liberal yet substantive approach. Conceptions that do not satisfy the preceding condition will not be considered as distinctively liberal. In addition, the following discussion presupposes a distinction between the concepts of freedom and autonomy and focus on the former (Feinberg, 1986; Dworkin, 1988: 3–33). My argument relates to the latter insofar as freedom facilitates personal autonomy, both in its development and exercise. As a result, the issues raised about the value of health do not undermine value-laden conceptions of autonomy, e.g., Oshana (2006), but only suggest that health cannot sustain such a conception. Finally, the central distinction between freedom as non-interference and freedom as non-domination differs from that between negative and positive freedom (Berlin, 1958). For both strategies of defining freedom share aspects that belong to both sides of the classical divide. Non-interference and Its Perceived Weaknesses As stated in the Introduction, this section aims to reconstruct an underlying argument that could sustain the frequent claims that liberalism is an awkward match for public health ethics. A promising starting point would be to maintain that the liberal understanding of freedom as non-interference is at odds with the underpinnings of public health policy. The ‘harm principle’ stating that one's freedom may be legitimately constrained only in order to prevent harm to others is criticised as an insufficient corrective to the primary focus on individuals. Although its original formulation by Mill (1859) is significantly more complex (Dawson and Verweij, 2008), its rationale (...truncated)