The weakness of ethical thinking in public health: a case study

by Carl V Phillips

I continue to be appalled by what passes for ethical analysis in the realm of THR. This is clearly a symptom of the ethical failings of public health in general. Of course it is somewhat better to see someone actually trying to analyze ethics as compared to the normal “public health” approach of simply making a declarations about what should be done without any mention of what ethical goal they are basing that upon, let alone defending the legitimacy of that goal. The latter is a level of political discourse comparable to the average social media or comments section “debate”. But the attempts at analysis seem only to rise to the level of a freshman term paper.

The latest such analysis of ethics in this space is “Ethical considerations of e-cigarette use for tobacco harm reduction” by Caroline Franck, Kristian B. Filion, Jonathan Kimmelman, Roland Grad and Mark J. Eisenberg of McGill University. It appeared in Respiratory Research, which suggests a good rule of thumb: Do not get your advice on how to practice respiratory medicine from papers published in forums devoted to the study of ethics, and apply the same skepticism to an analysis of ethics in a respiratory medicine journal.

I have chosen to write a case study of this particular paper because (a) the authors seem to be genuinely trying to do what they claim, so the problems represent legitimate faults in the understanding of ethics in public health, not the intentional misdirection you see from tobacco controllers, and (b) these guys are not my readers’ heroes. But keep in mind that every one of the other “ethical analyses” of e-cigarettes I have seen in a health journal, whether written by detractors of e-cigarettes and/or THR or by vaper idols, is comparably flawed. At least these authors get credit for citing the author who I am pretty sure has written more serious analysis on the topic of THR ethics than anyone (ahem), which many fail to do, though they apparently did not read much of what I have written.

The paper also includes a simplistic summary of some of the science about e-cigarettes, as well as a simplistic analysis of the politics. Much of this is wrong, but I will just gloss over that in order to focus on the ethical analysis. Probably the best lesson from those bits is that it is always a mistake to try to summarize a complicated body of science en passant in a paper that is not about summarizing that science.

In the abstract and again in the introduction, the authors assert:

Several ethical issues have been identified pertaining to their use both as recreational products and harm reduction devices, including their potential appeal to non-smokers, their potential to act as a gateway to cigarette smoking, and their potential to renormalize a public smoking culture.

Notice any problem here? The three items on that list are not actually ethical issues. This is a list of material features of the world. A material fact (or uncertainty about it) is not an ethical issue; you can declare it to be fortunate or unfortunate, but it is neither ethical nor unethical. These authors, like most public health people writing about practical ethics, skipped over two crucial steps: They need to identify what particular action (presumably, policy) they are subjecting to ethical analysis, and they need to identify their basis for assessing its ethical goodness. Only with those two in place is it possible to say something like “the ethics of this action according to ethical rule X hinges on e-cigarettes’ potential appeal to non-smokers.”

You might think that they covered those two steps and were just sloppy in their summary here. Or perhaps they were approaching the analysis a different legitimate way, noting a particular worldly phenomenon and attempting to catalog the many policies that could affect it and analyzing their ethics, ideally based on various ethical rules. But of course they are not attempting the second in this little paper. While they try to explain what ethical bases they are using, they fail to identify what actions they are analyzing. It is possible to analyze the ethics of something only if it is an act of an ethical actor, which basically means an adult human or collection thereof.

The (not at all unusual) conflation of states of the world with ethical questions is a symptom of the ethical blindness in the health sciences. In spite of setting for themselves the goal of analyzing ethics, the authors cannot escape assuming that any fact about the world that piques them or their colleagues across the hall is, ipso facto, an ethical issue. They gloss over the question of what action they are analyzing because they assume that they can implement any change in the world by fiat, and are apparently oblivious to the additional major ethical questions that exercising such power would introduce.

They go on in the abstract to say:

Specifically, our framework draws upon tensions between utilitarianism and liberalism in public health ethics.

As with most every paper by public health people that makes this pronouncement (there have been several about e-cigarettes), the authors apparently do not understand what the words in this sentence mean. Utilitarianism is a precisely defined (in theory) concept which they do not actually invoke.[*] Liberalism (libertarianism) is a broad family of possible ethical rules, not a well-defined rule in itself.

[*Utilitarianism is a welfarist ethical rule. Welfarist rules are those consequentialist rules (i.e., the ethics of an action or policy is judged based upon its consequences, as opposed to upon the action itself) in which the consequences are measured in terms of the welfare (happiness, well-being) of affected people. Utilitarianism imposes a particular rule for aggregating the overall social measure across people, by adding up each individual’s net change in welfare across everyone. My parenthetical “in theory” comment was a recognition that the difficulties of somehow measuring and adding up people’s welfare make this rule well-defined as a concept, but not in practice.]

A bigger problem is that public health people who casually assert that there is such a dichotomy seem oblivious to the fact that most liberal ethics and utilitarianism usually lead to almost exactly the same ethical conclusions regarding policies about individual consumption choices and commerce. This is a corollary to economics’  invisible hand theorems, which show that under certain assumptions, and taking the distribution of wealth as given, welfare is maximized (at least in the short-run) by allowing freedom of consumption choices and commerce. Put more simply, people generally choose to do what makes them happiest, given their options, and the free market facilitates maximizing that happiness. Of course there are many tensions between these two bases for ethical judgment. Some of these are irrelevant to the present discussion (e.g., redistribution of wealth will usually result in a gain by utilitarian measures, but violates some versions of libertarian rules), but others might be (e.g., if someone’s preferred choice hurts others’ welfare, or if people are acting based on incomplete information). But these public health attempts to analyze ethics do not tend to understand such nuances, in part because they seldom understand what “utilitarian” means, or even what welfare is.

Consider one of only two places in they actually claim to compare the implications of utilitarian and libertarian ethics. Their entire analysis of the ethics appears in this one sentence (what came before it is simple background information):

From both utilitarian and liberal perspectives, misinformation through the provision of inaccurate comparative risk is fundamentally unethical for its failure to allow consumers to make informed choices, and for effectively conveying the message that smokers may as well continue to smoke [59].

Reference 59 is to me. Right author, wrong paper. I have written quite a lot about both the libertarian and welfarist arguments against disinformation in this context, but not in that paper. I thank the authors for the citation and the paraphrase of the title of that paper (though why they chose an inferior paraphrase over the iconic original, I do not know). But that was not the right one of my writings to cite, because it does not analyze either utilitarian or liberal ethics.

In that paper, I give welfarism only a passing mention, and do not address libertarian ethical rules at all. That paper’s ethical analysis is brief (for it is an empirical study, not an analysis of ethics) and focuses on much simpler rules of conduct. My claim there, which is neither libertarian nor welfarist, is that the lying is per se unethical, and that it furthermore violates the primary rule of health ethics, that people must be allowed to make informed choices about their health. The latter bears some family resemblance to a libertarian argument because it is about the ethics of actions (rather than their consequences) and invokes rights, but it is actually a much stronger condition than a mere negative right of liberty. The informed autonomy ethic affirmatively obligates health professionals to actively inform people in order to facilitate their informed free choice. Thus it constitutes a positive right (to be given the information) not merely a negative right (to be free of someone stopping you from making your choice).

It is certainly true that lying about THR harms welfare, and thus is unethical from a welfarist perspective. I have argued that extensively, but not in the cited paper. However, not all libertarian rules of ethics condemn lying or and many libertarian ethics do not allow for there to be any positive rights, which necessarily impose affirmative obligations on others. Thus my position there was flatly contrary to some libertarian views. For example, there are libertarian rules (which are endorsed by some people) that allow caveat emptor. That is, you have the liberty to make your own choice, but someone trying to sell you on a choice has the liberty to freely speak and act to try to manipulate that choice, so long as they do not force you, and it is up to you to deal with that. Most of us agree that this would be a terrible rule to live by, but is is one libertarian ethical rule, and thus it is wrong to make a blanket assertion about what libertarian rules imply on this issue.

At this point, it should be apparent that we need to figure out what specific rule these authors had in mind when they invoked the broad category of “liberal perspectives”. Similarly, we have to figure out what they mean by “utilitarianism”, since it is apparent that they keep using that word, but it does not mean what they think it means. These problems might represent mere gaffes in a paper that made a passing reference to ethical analysis; they are fatal flaws in a paper that focuses on ethical analysis. In fairness to these authors, such fatal flaws can be found in almost every such paper in public health.

So, scrolling back,

Specifically, our framework draws upon tensions between utilitarianism and liberalism in public health ethics, the former aiming to produce the largest public health gains through the greatest reduction in the burden of disease, and the latter holding paramount individuals’ right to self-determination in health.

Ok, now we know how they are misusing “utilitarianism”. Credit to them for actually defining their terms, though a major penalty for using the word incorrectly. The goal they describe is what I have dubbed the “public health pseudo-ethic”, and it can be described as a special-interest goal, but not as an ethic. I refer to it as a pseudo-ethic because it gets discussed as if it were an ethical rule, but it is completely indefensible as such. No one ever defends that goal on the basis of any established ethical system, and indeed they could not because there is no ethical theory that supports it. It is not welfarist, because the measure is not welfare, but merely one arbitrarily-chosen component of welfare, reduction of disease. No one ever tries to defend this goal by claiming that if it were adopted as an ethic it would make the world a better place. It clearly would not do so. It certainly does not reflect the empirical reality of how anyone chooses to live their life.

As for what they characterized of a libertarian ethics, it is narrowed somewhat from just suggesting that “liberalism” is a well-defined rule. But it is still presented sloppily. It is only later still (for some reason, in the section entitled “e-cigarette safety”) that they imply that they are actually referring to informed autonomy:

…promoting autonomy, or the right to make individual decisions with regards to one’s life choices, requires the provision of information concerning the risks and benefits associated with a given behaviour and with voluntary choice [32].

So after a little scavenger hunt, we can conclude that what they mischaracterize as liberal ethics is actually the informed autonomy principle. Sadly, reference 32 is not to one of the classic statements about this principle, as you might hope, but from a tobacco controller article from 2005. They continue:

This rights-based position is compelling given that the majority of e-cigarette users are current smokers attempting to quit or reduce their number of cigarettes smoked [33].

Having finally let us know what they mean by the liberal ethic, they immediately fail the test of knowing what that rule means. As I already noted, it is not entirely a liberty-based position, in that it imposes affirmative obligations on some actors. But still it is a deontological rule, meaning that the ethical rule applies to actions themselves, not their consequences. It is about rights and obligations that exist apart from the details of the situation. Thus the entire rest of the sentence is nonsense. What they have said here is analogous to “‘thou shall not kill!’ is compelling in this particular case because the person you were going to kill is a nice guy.” Either the principle is an overarching ethical rule or not. If you are assessing the results it would bring about in a particular circumstance before deciding, you are engaging in consequentialist ethical reasoning of some sort, not following a deontological rule.

(And, incidentally, reference 33 is to a convenience sample survey and therefore cannot support the claim attributed to it. I will now return to ignoring them getting the science wrong.)

Continuing:

While autonomy may be compromised through the influence of nicotine addiction, the consequences may be less pronounced where this choice consists of selecting between alternative sources of nicotine (of potential equal or similar satisfaction), rather than choosing between indulgence and abstinence.

And with that, they resolve the question of whether they even understand what autonomy is. A common trope in some of the anti-tobacco junk science is to declare that “addiction”, whatever that means, causes (or perhaps is) a loss of autonomy. But those effects are not a matter of autonomy, but a change in the preferences that motivate how that autonomy is likely to be exercised. This misuse of the term implies that autonomy only exists if someone is utterly indifferent about what choices to make (which, ironically, would render autonomy practically worthless). Once again, the misuse of this term elsewhere in the public health literature is bad enough. But when someone is trying to write about ethics, it is yet another fatal flaw to get it wrong. Whatever the people making those “loss of autonomy” claims think the word means, in the context of ethics it refers to prohibitions against one actor constraining the actions of another (and, perhaps, also to manipulations that are not literally force but have the same effect).

As for the rest of that sentence, whaaaat? Again, consequences. I suppose we can charitably interpret this as the authors proposing to assess the consequences of adhering to the informed autonomy ethic. That, unlike the previous sentence where they proposed to judge the validity of the deontological rule based on its consequences in the particular case, is perfectly reasonable. However, they do not actually assess the implications of that rule, as applied to a particular act, based on the consequential rule (the pseudo-ethic) that they are purporting to analyze. Rather, this is some weird sludge of judging the consequences of some phenomenon that stands apart from ethics (because there is no act in sight) based on a non-consequentialist ethic. Huh?

This continues for a bit, but I cannot stand it anymore.

Anyway, patching all this together, we can surmise that the supposed goal of this paper is not an analysis of two competing ethics, but about the tension between the ethically indefensible goal implicit in most public health discourse and the actual primary health ethic. Ok, that is an interesting exercise. Unfortunately, they fail in their analysis of that question also.

Reconsider the above-quoted passage about lying. It is now clear that the reference to my paper was arguably defensible because they are not actually talking about a libertarian ethic, but about the informed autonomy rule I briefly addressed in that paper. (Too bad they did not pick up on how to properly describe it.)

But they still have a serious problem. Assessing whether particular lying might further the public health pseudo-ethic is a complicated empirical question, which I did not address in that paper. It is easy to make a blanket argument that misinforming people inevitably lowers their welfare because they can then not correctly assess their tradeoffs. (This is a bit of an oversimplification in various ways that I will not go into here, but it is a solid starting point: people cannot maximize their welfare if they have bad information.) However, while unmitigated lying about THR pretty clearly harms not just welfare but also the goal of the public health pseudo-ethic, it is entirely possible it might be that some particular act or policy of disinformation could further the (ethically indefensible) public health goal.

For example, it could be that misleading people into thinking that e-cigarettes are 5% as harmful as smoking, as in the current campaign from certain quarters of public health, could dissuade some nonsmokers from taking up e-cigarette use. (The implication that this furthers the pseudo-ethic goal assumes that e-cigarettes cause a net positive increase in disease risk, which is not a foregone conclusion, but for present purposes assume it is true.) I have suggested that it  this claim was concocted to facilitate supporting e-cigarettes as a “cure” for smoking (5% is a lot lower than 100%) while still maintaining justification for severe government controls on e-cigarettes (5% of the risk from smoking would make it easily the second-most harmful product many people choose to consume in the West). But a closely related explanation it is an attempt to mislead people in order to maximize the goal of the public health pseudo-ethic. That is, the goal of the claim is to trick some nonsmokers who might experience welfare gains from taking up vaping (based on realistic estimate of the health risk) into believing that would be worse off doing so because of the substantial risk, and thus increase their adherence to what public health wants them to do. Notice that this is a fail in terms of a genuine utilitarian ethic, since it would lower their welfare, but is a gain according to the pseudo-ethic.

That would be interesting to analyze. But the paper fails to do that or anything similar. Indeed, they do not analyze any particular policy or action, and so all of their conclusions are based on nothing — again, they are missing one of the fundamental steps in doing an ethical analysis of a policy, identifying the policy.

In the only(!) other mention of the comparison they claim to be exploring, they write:

A useful paradigm that reconciles liberalism and utilitarianism in illustrating the impact of displacing a high-risk activity with a low-risk one is the risk/use equilibrium. For instance, if e-cigarettes reduced a smoker’s risk by 99 %, for every smoker who switched to e-cigarettes, 100 non-smokers would need to initiate e-cigarettes…. Consequently, it is unlikely that e-cigarettes would result in net public health harms despite the inevitable uptake of the product in a non-smoking fraction of the population. …. In practice, sound public health policy can sustain autonomous choices with deleterious consequences to the extent that these do not outweigh net public health benefits.

So they present the obvious simple calculation that shows that the mere existence of e-cigarettes results in a net gain in terms of the public health goal, (for the short-run, that is). But what “sound public health policy” are they talking about? We all know that e-cigarettes and snus reduce population risks compared to a world with just cigarettes. But that is just background information, not ethical analysis. Unless they are proposing a policy of eliminating those products from the world, while for some reason keeping cigarettes, this calculation has no relevance to ethics (which is to say, it would not even have relevance to ethics even if the public health pseudo-ethic were a defensible ethic). Assessing the consequences of a material fact about the world according to some goals is an analysis similar to consequentialist ethical analysis, but it is not a matter of ethics. Even more of a problem, it does not make any sense whatsoever to talk about deontological ethical rules in the context of phenomena that involve no acts that could be subject to deontological rules.

If they actually analyzed a particular realistic action or policy, the arithmetic they present could be used to show that the predicted result (which itself would have to be assessed based on what an analysis showed to be the real, not fantasized, impacts of that policy) would further the public health pseudo-ethic. If the action also fulfilled the requirement for informed autonomy, then they would have shown what they claimed (for that one action). They did not do this.

Their comparison of the two rules continues with…, er, nope, that was the entire content that related to their stated mission. The paper mostly consists of a meandering survey of things that someone once asserted about the science, politics, or history related to the topic, or merely furled their brows about.

They have only a couple of other ethical assertions, which are even weaker than their claimed analysis:

Beyond any immediate emission concerns however, the ethical arguments surrounding second-hand vapor exposure are those that apply to tobacco cigarettes: exposure to e-cigarettes should not be imposed upon those who do not choose to use them, providing a strong argument for use restrictions in public places.

How’s that again? Is this bold assertion based on the public health pseudo-ethic? That seems like a stretch since the environmental emissions are clearly approximately harmless but a policy restricting vaping could encourage smoking, thereby scoring less well according to the pseudo-ethic. Is it based on the ethics of informed autonomy? It is difficult to see how it could be, since it is basically the antithesis of autonomy. So apparently they are pulling another unidentified ethical rule out of thin air, asserting it is valid, and judging this question based on it rather than the rules they claim to be analyzing, without ever telling the reader what the rule is. In other words, they have descended back into the usual relationship between public health people and ethics: “whatever we personally feel like is the right conclusion is in a particular case”.

But perhaps in order to make the above assertion look like legitimate analysis, they also write:

Regardless of their industry ownership, e-cigarette companies would nevertheless have a vested interest in maximizing the number of long-term product users. The ethical onus then falls on governments to restrict the influence of industry through appropriate regulations targeting product manufacturing, availability, and use, devised in light of public health interests.

What ethical concern? What ethic? What is an ethical onus? What is the justification for curtailing people’s free choice? This is supposed to be an analytic paper, not just another worthless statement of personal opinion. So where is the analysis?

I have no idea, and I will leave it there. Given that this is what passes for ethical analysis in health sciences, it is little wonder how poor the ethics of public health people are. It is not all that difficult to find a legitimate ethical analysis and use it as a guide for writing a new one. It is even easier to find a colleague with a decent liberal arts education who can explain what “utilitarian” and “liberal” actually mean. But they did not even try, presumably due to the Dunning-Kruger-fueled arrogance that permeates public health. And, as I said, this paper is above average for what passes for ethical analysis in public health.

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15 responses to “The weakness of ethical thinking in public health: a case study

  1. natepickering

    The authors’ usage of “liberalism” is so far removed from the bastardized meaning of that term in the contemporary American lexicon that I’m willing to venture a guess and say the authors are not American.

    • Carl V Phillips

      It is a UK published journal, making the term more useful. However that publisher allows either US or UK spelling and grammar, and this paper was mostly the former.

      Anyway, there is nothing wrong with using either term, so long as it is clear. In a proper ethics paper, it should be taken as a given that “liberal” means libertarian. I switched it for the obvious reason, that my blog is often about politics and not philosophy, and “liberal” has various meanings in politics.

  2. Pingback: When Human Beings Are Subsumed Into a Committee | Bolton Smokers Club

  3. Very productive analysis, which makes a fascinating read – thank you!
    I call it “productive” even though you fail to find any definite, clear, consistent ethical underpinning in the article. For the good reason that there isn’t one to be found. As you said:

    “This continues for a bit, but I cannot stand it anymore.”

    I doubt that continuing further would have made you reject the null hypothesis about the ethical foundations of public-health!

    I think you get to the heart of it here:

    It is possible to analyze the ethics of something only if it is the act of an ethical actor, which basically means an adult human or collection thereof.
    The (not at all unusual) conflation of states of the world with ethical questions is a symptom of the ethical blindness in the health sciences.

    Because you’re looking for real ethics in public-health, this statement is clear and prescriptive: if there are no ethical actors, then whatever might be going on is not ethical investigation.

    But let’s look at how public-health “ethics” does follow this prescription, or at least appears to. This quickly suggests a fun alternative hypothesis. Conflating states of the world with ethical questions is not a symptom, but the fundamental origin of the confusion. There are ethical actors in public-health “ethics”: the products (cigarettes, e-cigs, any other “sinful” product) themselves are the central ethical actors, promoted to this status by a kind of pathetic fallacy.

    Of course the corollary to this kind of violent stretching of the normal notion of an “ethical actor” is that, to follow it down its own rabbithole, you have to do equal violence to the normal rules of ethics. Because cigarettes and e-cigs, once assumed as ethical actors, are a very special kind of ethical actor:

    1. They’re invariably and inevitably unethical: this is how, as mere “states of the world”, they can seem to demand an ethical response;
    2. Being non-human, they’re not amenable to ethical discourse or persuasion;
    3. They somehow simultaneously manage to be human-like, in that they’re invariably and inevitably deceptive: to be deceptive, you have to be capable of some kind of communication with other ethical actors in the first place.
    4. Following from 3: they are not just ethical actors, but communicators about ethics. How they manage this while being non-human is not clear at this point.

    This whole construction is entirely ridiculous, without the one word that makes sense of it. Carl will already have guessed what this word is, but I’ll save it til later (since I’m dealing with rhetoric, I think I’m allowed to practise some myself!).

    What obscures the ridiculousness is a fascinating fifth factor: a kind of extended, repeated synecdoche. It’s hard to pin down the underlying assumption that e-cigarettes etc are not just ethical actors, but the central ethical actors in the whole business, into a clear statement to that effect. This is because public-health uses synecdoche to slide around the issue. The threat is sometimes located in the e-cigs themselves; sometimes in the Evil Manufacturers; sometimes in the (duped) humans who use them (or rather, are used by them); sometimes in advocates like Clive Bates or Carl himself.

    The statement “the above article was written not by Carl, but by e-cigarettes” is clearly laughable: but although this is what a typical ad hominem (ad rem?) attack on it ultimately amounts to, you can’t pin the attack down to this one statement and laugh at it. Synecdoche allows the locus of the evil agency to never settle for long in either the e-cigs themselves (where the idea of an object having agency invites an obvious attack) or in the humans associated with them (where, you’d at least hope, there’d be at some respect paid to the idea that humans may be rational and autonomous).

    And this conveniently allows both to be tainted by association with the other. E-cigs, as objects, must be evil because of the humans who advocate them (Evil Big Tobacco, or Evil Big-Tobacco-Analogue E-cig Companies). Certain people (vapers and advocates) are not worth listening to, whatever their arguments, because they are under the influence of e-cigarettes, which are evil.

    (Although the “pathetic fallacy” is termed a fallacy, this kind of reverberation is, poetically, a completely correct use of it. The pathetic fallacy is not a one-way movement, which removes the Flying Dutchman’s rage from him and locates it only in the violent storm that accompanies him, leaving him empty. His own rage whips up the storm, which then echoes its power back to him again, magnifying him as a character).

    So it’s fun to cut this Gordian knot by demanding something more definite than poetic from public-health. Who are the ethical actors they’re considering? Clearly not humans, as Carl’s analysis above shows. So let’s go with the assumption that the central ethical actors are the e-cigs themselves.

    However ridiculous that may seem, it explains a lot.

    (1) above explains why it’s impossible for public-health (PH) to consider that vaping (or smoking) can have beneficial effects.
    (2) explains why PH are utterly resistant to rational argument. If your starting position is that a state of the world is ethically loaded, you’re not going to be capable of listening to arguments about other states of the world. The original fallacy is infectious, so that those other states of the world will also be ethically loaded for you, over-riding the merits of the argument and making it irrelevant.
    (3) and (4) are extensions, by pathetic “reverberation”, of (2). Humans who use e-cigs or advocate for them acquire the (un)ethical characteristics of e-cigs themselves. Therefore it is pointless to engage with vapers or vaping advocates as rational, autonomous human beings. This makes coercion the only course of action.
    (3), about deception, explains why the ethic of informed autonomy just doesn’t get any traction on PH practitioners. E-cigs are posited as essentially misinforming, and so powerfully misinforming that merely human information efforts are not sufficient to restore autonomy.

    You deal with this in the discussion of “addiction”:

    Whatever the people making those “loss of autonomy” claims think the word means, in the context of ethics it refers to prohibitions against one actor constraining the actions of another (and, perhaps, also to manipulations that are not literally force but have the same effect)

    True, but if the objects themselves (e-cigs) are promoted to the status of “ethical actors”, then PH’s “loss of autonomy” argument can stand as an “ethical” argument – though only in the special kind of ethics that follows from treating objects as ethical actors, of course!

    I think what I like best about this hypothesis is that it explains the main problem pointed to by your post, which is the complete lack of proper ethical thinking in PH. If objects are treated not just as ethical actors, but as the central ethical actors in a situation, they drown out ethical consideration of other actors – just as a “terrorist threat” drowns out rational political discourse.

    It’s because e-cigs are treated as such an overwhelming ethical threat that PH feel under no obligation to act ethically themselves, or to treat the human beings whose lives their policies affect as ethical, autonomous beings. (The word describing this kind of overwhelming ethical threat is: demon).

    • Carl V Phillips

      Wow. Thanks. I think that comment was better than the original post. It certainly contained more original analysis.

      I think I am going to have rework a couple of chapters I am working on with these insights in mind. (Seriously — if you would like an acknowledgment in the book, maybe even credit within the text, drop me a note about how you wish to be identified.) I also am going to work “synecdoche” into it, since it is such a perfect hook for the concept.

      I will offer this amendment to your conceptualization: The broad failing of public health ethics is the unthinking adoption of the pseudo-ethic, a rule which tends to make the world a worse place when applied outside of medicine and medical-like settings (e.g., making sure restaurants are clean) where it is about fixing a clear disease state. But when it comes to temperance type issues, the demonic possession metaphor I have introduced can be extended beyond deny human agency and preferences (which is how I have used it to date) to there being a belief that the demons’ actions are subject to ethical analysis. And, as you said, the demons are given form as the products themselves, but still treated like actors with volition because, well, they are demons.

      The original form of the demon metaphor is sufficient to explain some of the points you note, like the skipping over attempts at rational persuasion of the real actors (product users) to trying to coerce them; their actions are not subject to rational persuasion and their choices should not be honored because they are acting on someone else’s volition. But the next step is required in order to explain why they feel (and it is clear that they really adamantly *feel*, in an animalistic way) that whatever is causing this is subject to ethical judgment because it is not just a piece of material reality, but an anthropomorphic demon. Of course they cannot just say they are talking about an anthropomorphic demon because that would make clear that theirs is a mystic rather than scientific enterprise. So (just paraphrasing what you said because I like it) they embody that demon in an ever-shifting series of actual actors: industry, advocates, consumers.

      (The more I think about it, the more I am *really* liking this. Yours may be the biggest insight I have read about public health ethics since… ok, maybe ever. Again, thanks.)

      • I’m really glad it’s a useful insight, and very happy to have contributed something to the book! (Keep us updated on progress on it towards publication, as if it’s discussing this kind of thing it sounds as though it’ll be fascinating). Please do credit me in whatever way seems appropriate in the final form – my full name is Seb Thirlway.

        As you wrote in your reply, it’s a kind of extension of your own demonic possession metaphor; so much that for a while after writing my post I thought my idea was implicit in your metaphor. But after reading your reply I agree that it isn’t.

        Granting that the “demonic possession” metaphor is a true description (which it isn’t of course), for the purposes of argument, then some kind of obstruction – or even annihilation – of human agency and preferences is going on. Isn’t that already a Bad Thing (ethical judgment)?

        It is a Bad Thing, but it’s not an ethical judgment, because for an ethical judgment to be made there have to be ethical actors involved. (This statement of yours is absolutely key: it’s what set off my train of thought). I think a good way of characterising the difference would be by imagining an oncologist, who sees cancer’s terrible debilitating effects on humans and deplores the state of the world which has cancer in it; then imagining another oncologist who condemns this state of the world.

        The first oncologist is no less committed to or capable of fighting cancer because s/he isn’t armed with an ethical judgment about cancer’s “actions”. The second oncologist’s ethical judgment is obviously ridiculous, like the mediaeval church courts which excommunicated plagues of rats and grasshoppers, and completely extraneous to the practice of effectively fighting cancer.

        With disease, I think in practice these illegitimate ethical judgments don’t creep in. When diseases are personified (for example in CRUK’s campaign for donations “Let’s Beat Cancer Together”), it remains a pretty harmless rhetorical device of convenience. The interesting stuff happens in the “public-health pseudo-ethic”.

        I was a bit confused at first by this:

        “the demonic possession metaphor… can be extended …to there being a belief that the demons’ actions are subject to ethical analysis.”

        because of the word “analysis”. You use the phrase “ethical judgment” instead later on, which I think fits better. “Analysis” threw me off your point, because this “demonic possession by an ethical agent” metaphor (clumsy name!) strikes me more as a kind of atomic, unexamined black box element in public-health thinking, a machine that reliably and automatically spits out a plausible-looking necessity for ethical condemnation (which, in your words, PH practitioners “really adamantly *feel*, in an animalistic way”). Not something that’s the result of ethical analysis, rather something that relies on _not_ being analysed for its power.

        But perhaps its own weird logic can be analysed, even though PH won’t do this. I certainly haven’t thought through the implications, but one thought is that the ethical logic is difficult to analyse because the relationship between e-cigs (for example), users and advocates is not one between possibly conflicting independent agents, but one of poetic, pathetic “reverberation”. PH’s insistence that this _is_ an ethical matter obscures this.

        Another rough initial thought is that this:

        “Being non-human, they’re not amenable to ethical discourse or persuasion”

        is a really _weird_ postulate for an ethical situation. (I might not be capable right now of properly explaining how). An ethical agent (thus subject to and covered by ethical judgment) who is simultaneously completely unaffected by ethical judgment, ethical argument or condemnation? That looks a bit like a 1=0 postulate, or even a singularity.

      • Carl V Phillips

        Seb, thanks for the additional reply. Continuing this conversation is really helping me hone my thoughts. You will definitely get an acknowledgement. Taking things in the order from your comment…

        What you offered was definitely an extension but was not already part of the theory/metaphor. Now it is.

        The “already a bad thing” point is interesting, and somehow tangential to key issues, which is itself very strange. You might think that it would indeed be a core problem for those who were thinking in demon-ish terms. It is true that a few of them harp on this “loss of autonomy” silliness. So some bit of it is there. But I think it would be dreadfully inconvenient for them to try to argue that mere removal of free choice is a bad outcome in itself, because their whole business model is built around removing free choice. So they can only argue it is bad because of the outcomes it produces.

        The analogy to the oncologist seems spot-on (especially the linking to the church calling down moral punishment on disease vectors), but perhaps your “they would never do that” concession is too charitable. We see that Dunning-Kruger-saturated group, even more than other medics, make faux-ethical pronouncements about smoking and other behaviors. It seems reasonable to suggest that this assigning ethical agency to behavioral states of the world may stem from their gut-level assigning of ethical agency to biological states of the world.

        You are right that I was referring to ethical judgment or, to expand that, assessment of the ethicalness of the behavior of an agent. Sorry — I tend to write these comments with less care than others things I write — conversation level rather than publication level.

        Re the content there, my original demonic possession metaphor was definitely a black-box concept. That was fundamental to it. So not only was there no need to reconcile behavior with preferences — because behavior was controlled by someone else — but there was no way to even analyze the source of behavior (other than via empirically observing associations) because the actions of demons were black-box by construction. There was no theory, even so much as assuming what we might consider to be consistency.

        With the extended demon metaphor, that requires us to actually picture an acting demon flitting from one non-actor construct to another, it kind of seems like maybe we have to peek into the black box a bit more. If I understand, that is your argument, and I share the feeling. Offhand though, it is not entirely clear to me what that would look like, so maybe not. Maybe the demon remains as arbitrary and inscrutable as ever. I am afraid that I am not understanding your “reverberation” point, so I am not sure what to say about it.

        As for your last point, it is indeed a tricky concept. Is there such an category of actors that is described by “not subject to any moral persuasion and deaf to ethical arguments” but also by “is an ethical agent, and thus subject to ethical judgment”? It would indeed seem to be a contradiction. If someone cannot engage in moral analysis then his actions might have bad consequences but cannot be said to be culpably immoral, as with young children or the weather. (I have no doubt that there is an extensive literature about this, so if this turns out to be a crux point, I will have to do some research because I do not really recall it.) We can imagine an actor that has the cognitive capability to understand the ethics of its behavior, and also has a moral sense, but that is somehow cut off from input even though it is producing output (demons might be very moral people in their own dimension, but interact with us the way we interact with bugs and so do not even know how to listen to our ethical discourse). Going down this path is interesting, but I am thinking it adds only flourishes with no analytic power, and thus — being a proper modeler — I think it ought to be left out of the model.

        That seems to push us back toward the black box version. In the expansion of the metaphor, the demons may have some properties of actors, rather than being merely like the weather, but since they remain unreachable and inscrutable there seems to be little value in letting that change the basic model.

        • Carl, thanks for the additional reply.

          (Apologies, this has turned out to be very long: up to you if you want to publish it; if you feel it’s over-long, please let me know).

          I think you’ve shown how difficult it is to open up the black box of the “demon” metaphor and make sense of it. This is a general difficulty in trying to understand, analyse and critique the “PH” mindset; there’s actually another example of this in your reply:

          “It is true that a few of them harp on this “loss of autonomy” silliness. So some bit of it is there. But I think it would be dreadfully inconvenient for them to try to argue that mere removal of free choice is a bad outcome in itself, because their whole business model is built around removing free choice.”

          That’s you pointing out the inconsistency, and it makes sense in this conversation. But it’s all too easy (and infuriating) to imagine how that argument would fly with the “PH” crowd. You might get something like this:

          CVP: How can removing free choice be wrong when e-cigs do it, but right when you do it?
          PH: There’s no inconsistency. We remove the freedom to make bad choices, e-cigs remove the freedom to make good choices.
          CVP: What’s your basis and authority for deciding what are “good” choices for people to make?
          PH: We don’t claim that authority. We’re agnostic about the vast majority of choices. But when it’s a matter of resisting demons (and we are, essentially, a resistance movement against the demonic takeover of the world), we have to step in.
          CVP: What’s your evidence for the existence of these “demons”?
          PH: We have evidence that people are often making bad choices. This is because they are possessed by demons. Go Back To Start, Do Not Collect $200.

          Annoying, isn’t it? It’s like a self-contained, self-supporting little subworld. And I’m more hesitant now about believing that my “e-cigs as ethical agents” extension of your demonic possession metaphor might be an effective lever into this world, which might help prise it apart. Which is not to say that either your metaphor or my extension of it are valueless – perhaps they are a bit effective, or will lead to something that is. I think my hesitancy is more a measure of the evident sheer impenetrability (and, in an odd way, self-consistency) of the PH mindset.

          So I’m not really sure where my idea of “sinful” products as the central ethical agents really leads – if anywhere. Can it lead to further analysis, leading to a better understanding of the basis of the PH mindset? Or does attempting to do this get bogged down in absurdities, like an “acting demon flitting from one non-actor construct to another”?

          My reaction to this implication you point out makes me quite nervous. Because my immediate reaction is something like “no, it’s not a demon flitting, you don’t understand my point – you’re being too analytical and scientific: you’re trying to separate an indivisible phenomenon into causal parts and effects”. The wider implication of this reaction is that, to understand PH, you have to forget about thinking scientifically – and I don’t like that implication one bit, which is what makes me nervous.

          But I am going to try to offer something more substantial than a slick assertion that “your rules don’t apply here” (which looks like exactly what it is: a universal get-out clause), though at the moment a lot of it is very speculative. If what I propose is unscientific, or unamenable to scientific analysis (and it very likely is, both), it might at least serve as one possible characterisation of PH, which might be useful.

          Your explicit suggestion that PH synecdoche implies a “demon flitting from one one non-actor construct to another” made me realise that this is something I _didn’t_ mean. What is missing from that analysis is the intuition that in speaking synecdoctically, PH are in some sense _accurate_: there is a congruence between their synecdoche and what they’re speaking about.

          Synecdoche, as a part of rhetoric, is perhaps ethically neutral. In scientific discourse, it (along with rhetoric as a whole) carries a negative value: to characterise an assertion as rhetoric is also to imply that it’s misleading, a mistake (e.g. in a possible reconstruction of Thales: “Water is a part of the world that is fluid, mutable but always remains water; there must be some arche underlying the whole world; water is a good candidate”).

          Thales, looking for an underlying principle for the whole, was scientifically wrong in choosing the part “water”. The world doesn’t in fact work like that. But what if there is something in the world which _is accurately described by synecdoche_? What would that be like?

          It would be something which you could talk about with equal validity as a whole or in terms of any of its parts; but whose essence can’t be sensibly located and isolated in any one of its parts. If there is such a thing, then talking about it synecdoctically would be the correct way to talk about it.

          You (and I, really) assert that the question of the “evil influence” in “sinful” products is a subject for rational scientific and ethical analysis. Questions like “where is the evil influence located? What makes it evil? Is it a deontological or consequentialist argument?” are valid questions.

          But in this exercise, where I try to get inside the minds of PH (not much fun: the safe word is “informed autonomy”, by the way, just in case I get lost in here) I’m saying that the question of the evil influence (as viewed by PH) is _not_ subject to rational scientific and ethical analysis: because it’s one of these odd “synecdoches in the world” things.

          There is an existing exemplar of this, outside PH. I was trying to grope towards characterising it in my earlier post, with “pathetic fallacy” and “reverberation”. It’s a phenomenon in which the essence pervades all the parts involved in it: people witnessing it, the outside world or part of it, even people talking about it.

          Perhaps a better world would be “communion”. The classic example is Greek tragedy: you can’t sensibly locate the essence of tragedy in any of the parts: the actor playing Oedipus, the chorus, or the audience. But you don’t get the essence without all three. There are plenty of other examples: religious ceremonies, concerts, political demonstrations.

          We’re far outside science here. Let’s drop, for a moment, the experiment of imputing any kind of scientific rationality to PH, and ask whether their (not our) view of the whole complex of [“sinful products”, people who use them and people who advocate them] fits as an example of this “communion”.

          I think it does.

          1) If it’s a communion, then you can locate the “demon” anywhere you like (in the products, the users, the advocates): not as an exclusive statement e.g. “the demon is in the product, and NOT in the other parts”), but as a drawing-out of whichever aspect of the whole suits your purpose at the time (rhetoric, again). Trying to pin down someone making this kind of statement to a definitive assertion (“OK, WHERE is the demon, now and at all times?”) misses the point. (My earlier assertion that the central ethical agent is the products themselves might be saved by a parallel: whatever the indivisibility of communion, you can’t have the tragedy of Oedipus without the character of Oedipus – but I’m not sure about this).

          2) Like artistic or religious communions, “sinful” products involve _performance_. There are many toxic things we inhale (pollutants from exhaust fumes, for example): but we don’t _perform_ inhalation of exhaust fumes, but do _perform_ inhalation of cigarette smoke or ecig vapour.

          3) The “communion” model eliminates certain difficulties of the “demonic possession” model. Under a pure “possession” model, with a possessing demon and a possessed person in a unidirectional relationship, some things are hard to account for. Why would anyone want to be possessed or allow themselves to be possessed? If the demon removes autonomy, how does it get round autonomy and enter in the first place? And how can “possessed” people still appear to be human, and use human things like rational argument to defend their demon (or deny its existence)?
          Treating it as communion rather than possession eliminates these difficulties. (If this diminishes the rhetorical power of the “demonic possession” metaphor, and makes the PH position seem more sensible, so be it: taking a leaf out of Carl’s book, I’m not going to abandon a line of thought just because it might hand an advantage to PH).
          Communion is voluntarily entered into, by performance – which solves the first two problems. And communion results not in outright possession, but in integration of the demon into your own existing person, which survives, if changed. (Think of the opposite case: “Let Jesus into your heart” – apart from seriously committed mystics, the idea isn’t that Jesus is going to replace everything that’s there already).
          Thus the “demon” of e-cigs can be also be detected in e-cig users and advocates, not because they’re possessed by e-cigs, but because they commune with e-cigs – they’ve integrated e-cigs into their own selves: I think mentioning the established phrase “communing with evil spirits” is more than just playing with words.

          If the PH view of the “demonic complex” of sinful products, users and advocates can be characterised as a demonic version of artistic or religious “communion”, that still leaves the question – is this characterisation in any way useful?

          I think it’s very useful in understanding the PH mindset, not just because it allows us to see as they see: it also allows us to see what they are. They are an answer to the question “how do you fight against demons?” – and not a new one.

          You definitely don’t fight demons by disputing with them (Satan can out-argue anybody). Condemning them doesn’t do much either. Praying privately to God might help, but not much. You can destroy their vessels. But there’s a limit to how many vessels you can destroy (as everyone knows, demons are legion), and private destruction isn’t good enough. You also need to establish your own, hopefully stronger communion. You do this by a _performance_. You hold masses or ceremonies to establish a righteous communion against the evil one. Perhaps you perform sacrifices. Best of all, you combine all of these into the perfect demon countermeasure: the auto-da-fé. Everyone is forced to attend (or face suspicion that they might be influenced by demons themselves); it’s a religious ceremony of communion; you publicly condemn the demons; _and_ you publicly destroy their vessels, by burning them at the stake, for example.

          Isn’t this a good description of PH? Of the WHO’s behaviour towards THR products, for example? That PH are also practising communion explains a lot about them: their aggressive and really remarkably thorough and wide-reaching response to backsliders, for example. Just like a concert or a play, PH’s power depends on communion. A person, agency or government who dissents is fatal to the suspension of disbelief essential to the project, just as much as the infuriating person next to me who coughs, shuffles around, fiddles with their programme or lets their mobile ring (at a classical concert), or only pays attention to the band through their cameraphone (at a rock concert). And this is why “denormalisation” is so important. Allowing people to smoke or vape without encountering immediate condemnation detracts from the universal communion which is essential to fight the demons. It’s like making attendance at an auto-da-fé optional, so that the Grand Inquisitor is put off his stride by depressing thoughts of people (probably crypto-Jews) staying at home, sniggering.

          Only yesterday I was walking along the street, vaping. A boy of about 8 came towards me on his scooter. I said “Hi”. He said “Smoking is bad for you”. I couldn’t think of anything to say. Where did he get the power to talk like that to an adult stranger? (My niece often says rude things to me, about the hairs up my nose, for example: but I am her uncle) Answer: communion. By saying that the boy was communing with all the people who’ve told him that smoking is bad, all his classmates who agree, and it made him feel powerful – perhaps not even against smoking, which he probably doesn’t care about, but against all kinds of other scary things.

          I don’t mean to disparage anyone’s efforts to critique PH’s “scientific” pronouncements in scientific terms (least of all Carl’s). That’s very important and has to happen. But I think it’s equally important to realise that PH’s “sciency” costume is only a costume, and not to over-estimate the power of rational, scientific discourse to persuade these people. I’d go as far as saying that scientific discourse can’t touch them, because PH pronouncements – all those endless “studies”, press releases and conferences – are not just not scientific, but _not even assertoric_.

          They’re performative utterances. Their importance arises from them being uttered, heard and attended to, not from their truth-value. And they help build the communion of PH, which like all communions, is _fun_. PH are enjoying themselves, at the rock-concert/auto-da-fé they’ve organised.

          That parallel also suggests how they might view criticism. A scientific critique is like the boring man who stops the music (perhaps even turning on the uglylights) to announce over the PA “Would the driver of vehicle registration C247WTY please return to the carpark – you’re blocking the emergency exit”.

          I realise this is very long: apologies to Carl for writing at such length on _his_ blog (I didn’t mean it to be so long); and thank you to anyone who’s stayed with me so far. I don’t mean to be depressing about the prospects of combating the PH pseudo-ethic: if nothing else, if there’s any truth in what I’ve written, it’s established that PH are nothing to do with science!

    • +2 :-)

  4. I echo Carl’s praise.
    “Synecdoche”. The Cambridge dictionary has it, but my spell checker does not. A lovely couple of examples in the Cambridge dictionary:
    “A pair of hands” to describe a worker.
    “The law” to describe a policeman.
    Those two examples are particularly good because they show two different states where the word applies equally. In the first, the pair of hands is smaller than the whole worker, and, in the second, the law is bigger than the policeman.
    I feel sure that, if one looked carefully, one would find that “Public Health” uses both applications with abandon.

  5. Umm, if you substitute “criminal” for “inhuman” or “demon” (or hark back to the days when demonic possession was a capital crime) you get someone who cannot be reasoned with but can be judged. Or am I missing something?

    • Carl V Phillips

      I assume that is in reply to the question of whether demons are ethical agents. Under enlightened moral ethics, we create categories of those who are subject to moral judgment. If they lack the cognitive ability to ever act morally (and therefore also cannot act immorally — see also the “God allows evil because without it there would be no good” argument), then they are not in that category. Someone who is merely too much of a dick to act morally, or is just following orders, is not off the hook — he is capable of moral reasoning, but merely not using it. A non-human animal or a human with sufficient cognitive impairment is not capable of being a moral agent, and thus cannot be judged on such terms.

      That does not, of course, necessarily mean that it is never acceptable to kill, or whatever, such an animal or individual due to the effects it has. Same with someone who is inextricably possessed by a demon that is hurting others, if there were such a thing. That is an entirely different ethical question.

  6. Pingback: “E-cigarettes are a gateway” is a genuine scientific claim | Anti-THR Lies and related topics

  7. Apologies for bad formatting in my last (lengthy) comment!

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