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!).