An excellent indictment of public health paternalism

by Carl V Phillips

This is mostly an outsource: Go read this truly excellent case against paternalism by a professor of public health at Boston University with the unfortunate name, Leonard Glantz. I do not recall reading any analysis of this caliber by a public health professor since…, well since I was a public health professor (and I cannot claim I wrote anything quite so good on this particular topic back then). It deserves the highest praise: I wish I had written that. 

From an expert in law and ethics, as LG is, we might expect this. On the other hand, there are a lot of people who claim expertise in law and/or ethics in public health, and most of them produce nothing that is any higher quality than is produced by public health’s supposed experts in epidemiology or sociology. For example, the post that LG is responding to is “Public Health Paternalism”, by his dean, Sandro Galea, a typical “public health” person who produced just what we might expect. (You can read and follow LG’s post without reading Galea’s and, as I said, you should go read it — I will not summarize it because you really will be glad to read the whole thing.)

My attention was called to these posts via a tweet by Clive Bates, who attached a twitter poll asking whether we thought Galea made a better case for paternalism or LG made a better case against it. I was very intrigued, because for someone to argue the case for public health paternalism — something I would very much like to read — he would have to (a) admit that public health is paternalistic, (b) admit that the ethics of that behavior need to be defended, (c) note what criticisms of that behavior are voiced, and only then (d) make a case against those criticisms. No one in public health ever does that. Ever. They just ignore the dubious ethics of what they are doing and plow ahead with it with an aristocratic holy smugness, like crusaders executing infidels because it is just obviously the right thing to do. Alas, Clive misled me. Galea offers no case for paternalism.

I cannot fathom how even two people (the current count, out of 61 voting) chose Galea in the Twitter vote. Even if someone personally believes that paternalism is justified, it is impossible to credit Galea with making a case for it. Instead, his post is pure standard “public health” misdirection in which he simultaneously tries to take offense that public health is accused of being paternalistic, suggest paternalism is justified, and deny that public health’s coercive paternalism is really paternalism. If you do read it, you cannot do so casually, because it requires quite a bit of thought to sort it out — it is garbage in terms of logic, facts, and ethical reasoning, but it is quite skillful political propaganda.

Galea tries to suggest that coercive paternalism is nothing more controversial than keeping someone from falling from a broken bridge, and yet he then admits that merely providing information would actually be sufficient in that case. He goes on to pretend that punitive government actions, propaganda, and emotional manipulation are merely “nudges” and goes onto a tangent about the legitimacy of actual nudges. He never owns up to the existence of the nasty strain of paternalism that gives public health such a bad name, let alone acknowledges there are strong ethical arguments against it. Failing those, he obvious does not then construct a defense against the challenges.

Anyway, LG intelligently and carefully demolishes what Galea wrote as well as the unstated and undefended premises that lie behind it. In addition, he argues that,

Protecting people from serious risks of harm they cannot protect themselves from is precisely what public health should be doing.

He implies, though does not fully argue, that it should end there. Of course, someone is free to argue that public health should be doing more than that. But no one ever does. They just do more without offering any justification for how that is even public health work, and without admitting there is anything problematic in their actions.

LG’s argument is the rare gem in public health discussions (on either side of the issue), in that it is careful and tight enough that it is possible to identify and debate the details (you can read my challenge to one specific point in the comments — assuming it ever appears after spending all day “awaiting moderation”). Moreover, it was a strong enough argument that it has me rethinking something: The above quoted line argues that a common claim in some THR discourse is misguided, namely those statements that actors who guide smokers to try a low-risk alternative are the ones really doing public health work. They are, of course, potentially benefitting the health of those they are guiding. But that is not public health any more than is bandaging someone’s injury or the paternalistic attacks on our individual choices from the “public health” people.

So that bit of our rhetoric is a potentially serious tactical error, because it implicitly concedes that the actions taken by “public health” people to manipulate individual choices that have no real public health implications really are public health. The only issue is merely whether it is the right manipulation. It is a huge and misguided concession — that tobacco controllers and their ilk really are doing public health work, but merely doing it wrong. I find myself thinking I should push back against that rhetoric. If you never read anything that causes you to say “hmm, I seem to have been thinking about that wrong”, then you probably should be reading better stuff (so scroll back up and click that first link!).

9 responses to “An excellent indictment of public health paternalism

  1. If by “guide” you mean coerce, then I’d agree with you that we should not say Public Heath should guide people towards vape. If by “guide” you mean “provide information” then I’ll have to say that, since the average person does not have a lab, it is legitimate to say that Public Health should be guiding smokers towards e-cigs (and NRT, but I draw the line at the black-label suicide/homicide drug. It should be a closedly monitored last resort for EXTREME situations. Yes, people, including at least one small child, have died from second-hand chantix.)

    I really want to read your comment, I hope it gets moderated soon.

  2. It seems to me that it is very difficult, if not psychologically impossible, to argue a case against ones own interests. The convoluted logic and omissions of Galea strike me as a self-defense mechanism. The mind continually deceiving itself in order to protect its host from a debilitating psychological insight that would undermine it’s psychological integrity.

    It may be skillful political propaganda, but these defenses always strike me as first and foremost self protection by means of self delusion. Galea has simply invested too much social and political capital to admit the truth. So instead he lies (to himself) mostly to protect his own investment.

    Still, the fact that he has become conscious of a problem in need of defense gives hope. The more these people feel it necessary to defend themselves the more those without such personal and political investment will see the truth.

    • Carl V Phillips

      Yes, I suppose that is true. I envision someone testifying at a twelve-step meeting for the first time, saying “Hi, my name is Sandro, and people are telling me that I have a problem.” It is not the full admission that supposedly is the first step to recovery, but the fact that he is at the meeting is a start.

  3. I am not sure I agree that:

    “Protecting people from serious risks of harm they cannot protect themselves from is precisely what public health should be doing.”

    …is meant as or is a complete and exclusive definition of public health. I think that is applicable where *coercion* is involved.

    A definition of public health needs to be widened to embrace opportunity as well as threats and risks. Widening choice and opportunity, promoting informed choice, and possibly shaping the ‘choice architecture’ (the default choices that are built into the design of many things) all count to me as public health, but don’t really meet the test in the quote above. Building cycle lanes in cities might be an example. On the threat side, harm reduction generally intervenes non-coercively to reduce risks that could be avoided completely by making different choices: e.g. needle exchanges, systems for safe rides home after drinking, pill testing in clubs.

    Sadly, we see anti-public-health when coercion is used perversely to deny or obstruct better choices – as with vaping.

    • Carl V Phillips

      Writing this, I am engaging in deep text analysis that is probably inappropriate for a couple of blog posts — as good as it is, LG probably did not spend 20 hours on his (maybe only a day if he already had the thoughts in mind), and Galea probably only spent a few hours. Context suggests that LG is not arguing the “serious” or even the “risks of harm” are necessary conditions, but the “cannot do themselves” condition is. The content suggests that he is really focusing on with the latter, though he does not use the phrase, is that there needs to be some genuine need for collective action — I interpret that to be his main thesis. Or maybe he was not consciously trying to make such a point, but ended up doing a very good job of it anyway (authors are not sole arbiters of the deeper meaning of their analysis, after all). Whether or not it is coercive is orthogonal to that. He argues in favor of coercion when an accepted goal can only result from forced collective action (e.g., industrial regulation) and against it where no collective action is necessary.

      The risk from not having complete information about food (like a calorie count) is not serious but getting that information is something people cannot do for themselves because of collective action problems. Thus it requires public (government or some equivalent) action or it will not be done. Similarly with your bike lanes: The only question there is arbitrary definitions — whether it should be jurisdictionally counted as public health or some other public policy. Either way, it can only happen by collective action and coercion.

      I doubt he would disagree with your “opportunity” amendment to his phrase, because that is a mere detail about calibrating the zero-point. That is, anything that can be viewed as an opportunity to improve upon the status quo can be recast as protecting people from harm — you just set the zero to be at the state where the improvement already exists and thereby make the present state one where harm exists. So I don’t really see a meaningful distinction there.

      When an individual stops someone from falling from a bridge, or figures out he needs an antibiotic, or recommends he try vaping, it is not public health any more than changing his oil would be public auto maintenance. Even though someone might benefit from some help, obtained through the market or social networks, there is nothing public about these actions or that help. There is no need for public action, whether coercive or not. General public education about a choice is a bit of a grey area in that it is inherently a public good (in the economic sense) and has public impacts. But consider that also in terms of other areas: It may be a public good to put out information about, say, how to protect your online security, and it may improve the overall level of online security, but no one would ever think of that as “public” anything.

      So offering good advice about THR is potentially pro-health for the targeted audience while offering anti-THR advice is anti-health. But it is not pro- or anti-public-health because it has no collective component. An act of medical malpractice may harm someone’s health but it is not anti-public-health and more than a successful surgery is a public health success. My point (the one you are presumably objecting to) was that to claim that offering someone good THR advice is a public health action, then any action affecting THR choices — whether coercive or merely informative (including misinformative) — is legitimately a public health action. If it is genuine public health, then collective action (necessarily coercion of one sort or another) is justified. It might turn out to have negative consequences, but if that is your argument then you have agreed that if the consequences were positive, then it was legitimate. Once you agree that this is the crux question, you grant legitimacy to claims like “keeping people away from these products is better for public health in the long run.” Moreover, you have concede that ground to the people who assume the right to decide what constitutes “better”.

      • Am I right in thinking this just a long-winded way to make a distinction between population interventions (such as seat belt legislation/speed limits, trans-fat bans, balcony height mandates etc) and health information/education? If the latter is also aimed at the population level surely it is all under the public health umbrella. Over time some things may move into the intervention camp as we’ve seen with trans-fats and now the UK sugar drinks tax, and also the recent approval of an e-cig that can be prescribed by the UK health service.

  4. I suppose you answered your own question: two people voted for Galea’s case precisely because it is “quite skilful propaganda”.

    Would be nice to see what that breakdown would look like amongst a more general but still engaged audience.

  5. Hey I think your “a rare gem in public health discussions” to :-)

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