Public Health: III. Philosophy

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III. PHILOSOPHY

Public health is the prevention of disease and premature death through organized community effort. While this community effort is often led by government, many nongovernment and quasi-public institutions play key roles in promoting the public's health. Public health as an idea is one of the most influential of our time, and has been an important force in changing the shape of the modern world and enlarging government's scope, if not its size, since the middle of the nineteenth century. The general idea that government and communities can systematically discover, anticipate, and relieve disease and social distress through collective choice and organization is relatively new in human history. It involves the complex and related developments of collections and analysis of statistics, the understanding of variations in disease patterns in human societies (usually called epidemiology), and government of sufficient scale and capacity to exploit these findings.

Public health's focus on populations and communities is its most distinctive feature and the primary source of its philosophical interest. The community perspective produces a way of thinking about disease and early death and their prevention, that often runs counter to the categories and assumptions of much of modern bioethics and other disciplines as well. Public health as an organized practice views disease and premature death from the standpoint of the community and its capacity for self-examination, reorganization, and modification. The community perspective, far from neglecting the welfare of individuals, strengthens society's ability to discover the causes of disease in individuals, and society's capacity to devise flexible and rapid means for controlling disease and preventable death. Bioethics has been interested mainly in the intersection of the worlds of public health and the individual and his or her autonomy, and far less in public health as a method, seeing this as falling outside its sphere into the world of practice, and into the realm of contingency, experience, and practical action (Dewey).

Considerations for a Philosophy of Public Health

Public health as a method bears a strong resemblance to pragmatism, with its emphasis on probabilistic and fallibilistic ways of knowing, on exploiting experience and action, and on the centrality of knowing and acting in the context of communities, institutions, and practices (Bernstein; Rorty). While it is true that public health has many roots in utilitarianism (the English reformer E. H. Chadwick was once a literary secretary to Jeremy Bentham), public health came of age in the United States and Europe during the late nineteenth century and the early decades of the twentieth century, when the causes and methods for preventing many deadly diseases were discovered.

At the same time, philosophy and the social sciences began to revolt against the formalism of previous centuries (Dewey), and in both the United States and Europe, in philosophy and the social sciences, the search for fundamental truths gave way to empiricism and pragmatism, to a greater stress on the parallels between social science and philosophy, and to courses of action guided by both results and experience (Feffer; Anderson). After World War II there was in the United States a marked retreat to the earlier formalism with the rise of analytic philosophy and the return to social contract ideas, factors in the tendency of bioethics and philosophy to ignore the more pragmatic way of public health. This is not to say that public health as an organized practice needs no further philosophical elaboration or justification, or that it can ignore questions about the limits of health policy in restricting liberty or the coherence of public health's use of the idea of the common good. It is simply to say that public health does not need first to be translated into utilitarianism or contract theory to become a social philosophy.

A philosophy of public health must accomplish four things. First, it must give a central place to the unique approach and method of public health, with its distinctive emphasis on community, and on the central role of the scientific method in formulating courses of action for social improvement. Second, a philosophy of public health must give priority to prevention, and must challenge and revise explanations for health problems with the community perspective, which is essential to effective prevention. Third, a philosophy of public health must set out and defend an adequate definition of the common good, taking into account public health's pursuit of the common well-being—measured in terms of rates of disease and early death—as the object of group or common action. Fourth, while the philosophy of public health must acknowledge the claims of individual autonomy and justify actions that limit liberty and autonomy, it must do so in a way that leaves the community perspective and the common good intact.

Health by Design: The Idea of Prevention

Prevention is the major focus in public health, and it involves as a minimum the imaginative redesign of social environments and communities to better promote health and safety, as well as the replacement of older models of the problems that need to be solved. A major part of the battle in public health, especially in applying public-health methods to modern problems of chronic disease, injury, and alcohol and other drug problems, is to redescribe these problems in terms of the community perspective, countering the individualism, so widely prevalent in much of philosophy and social science, that serves as a powerful obstacle to effective prevention.

Two recent examples make this point. In the case of alcohol, since the 1970s there has been a shift away from purely individual or agent-focused explanations for alcohol problems, based on the capacities, dispositions, and motivations of individuals who drink, and subsequently experience problems, factors like "loss of control" over drinking. With the public-health perspective, the focus is on the exposure of whole societies to alcohol, on the varying levels of total consumption among groups, and on such factors as price, hours of sale, and age limits in causing rates of problems. This approach does not seek so much to explain alcoholism (why some people drink addictively) but why rates of alcoholism rise or fall among communities, or over time (Moore and Gerstein).

In a similar way, highway safety since the early 1960s has witnessed a shift from individual capacities ("driver error," "driver negligence," "failure to yield the right-ofway," and factors beyond the control of agents, such as "acts of God") toward such factors as the exposure of drivers to highway hazards, miles driven annually, types of roads driven on, and the safe or unsafe character of the automobile. Exposure is a key variable in this redescription and often results in counterintuitive insights. For example, researchers have noted that "driver education programs" in the United States probably raise the level of death and injury because they expose more young people to the hazards of driving at an early age.

Public health has many similarities to modern applied systems theory and the policy sciences, with their stress on nonreductionism, on policy or systems knowledge rather than disciplinary knowledge, on systems-level (community-level) analysis, and on promoting change through novel interventions with high leverage potential, often deployed at places located far from the primary cause of the problems.

It is common to find public-health specialists, in their attempt to fashion new means of reducing disease, speaking of "agents," "hosts," and "environments," translating individual descriptions of problems into community descriptions. According to the interpretation of William Haddon, Jr., this framework's "agents" are "exchanges" of hazardous chemicals, ionizing sources, drugs, or kinetic energy, suffered by individual "hosts." The environment is the larger social and physical terrain of hazardous agents and hosts. The purpose of this strange language is to provoke new ways of thinking about old problems, and to give public-health designers free play in their imaginative search for new and innovative ways of reducing dangers, ways that are both effective and ultimately politically feasible. All three elements—hosts, agents, and environment—are potential targets for change and modification, with no priority given any one (Haddon).

This search for new societal arrangements is often expressed as the search for "conditions" that promote health or prevent disease, a point found in the Institute of Medicine's report The Future of Public Health, and its definition of the mission of public health: "the fulfillment of society's interest in assuring the conditions in which people can be healthy" (Institute of Medicine).

In one way or another, public health concerns collective choice. Public health is about how much alcohol is permitted in society (per capita consumption levels), about the frequency of highway crashes, about the number of drownings in a state or nation, and about the changes in environment, legislation, and public attitudes that will directly affect those statistics. This emphasis on social organization and social arrangements in public health does not reduce public health to a species of social causation. For example, to use the link between general consumption levels and occurrence rates of cirrhosis is not to say that society causes specific individuals to drink heavily or alcoholically. It is to say that because we have learned through scientific studies that society, through alcohol policy, can influence the levels and kinds of problems in society, it is accurate to say that society influences these problems, and can and should seek, within the context of democratic discussion and debate, to sharply reduce them.

Public Health and the Common Good

In the public-health view, the common good in public health means the good of individuals taken together as a group, as communities, or in terms of aggregate health and safety; this aggregate health, expressed as so many thousands of lives saved, is the object of organized government or community effort. The common good does not mean that each individual has the same or identical good in health and safety, or even the same interests. An individual with a genetic predisposition for colon cancer does not have the same interest in health and safety as another who lacks such genetic makeup. Yet both can be said to have a common interest in measures to promote health and safety and to reduce general risks to health and safety that all face, including risks from cancer. This is another way of saying that individuals can face threats to health and safety alone and in groups, using group efforts to reduce those threats.

The common good expressed in aggregate terms does not refer to a good that is separate from, and set over against, the good of the individuals who constitute a group at risk. It is rather that the good of the group is jointly consumed, producing a common benefit of thousands of lives saved and many thousands more who will avoid injury or disease. This common benefit of lives saved (and avoidance of disease) is taken as the expression of the common good and is the object or purpose of collective or common action.

For most public-health problems, the aggregate savings in lives is far smaller than the number of individuals at risk and whose liberty is to be limited. Put another way, and for most public-health problems, the group that benefits from protections is a much smaller subset of the group that is at risk. Thus, all who are at risk and whose liberty is limited by public-health legislation do not benefit; the benefit accrues for an unknown and unaccountable minority of the larger at-risk group. Because this good is expressed in the form of statistical lives, it is viewed as a savings for the community. Thus, it is not wrong to think of public-health measures as undertaken by a community for the sake of a common good, that is, the thousands whose lives will actually be saved. The slogan for public health should not be "The life you save may be your own," but rather, "The lives we save together may include your own."

Geoffrey Rose refers to the fact that communities benefit more from public health than individuals as the "prevention paradox" (Rose). The prevention paradox states that most modern public-health risks are sufficiently low and widely distributed—indeed, they often stem from mass behavior like driving automobiles, drinking, smoking—and that despite the fact that millions engage in the activity, savings in lives will measure only in the tens of thousands in any period.

Public Health and Autonomy

Some have used John Stuart Mill's famous point in On Liberty that only individuals can know their own good (Mill, 1975) to criticize many public-health measures—such as laws that require people to wear seat belts in automobiles and helmets when riding motorcycles, and requiring fluoride in the water supply—as paternalistic. These laws threaten the autonomy of individuals, and also threaten to usher in an era of vast, paternal, preventive government. Ronald Dworkin argues that "laws that promote the common interest insult no man … while laws that constrain one man, on the grounds that he is incompetent to judge are profoundly insulting" (Dworkin, 1977, p. 263). Dworkin is here arguing that seat-belt laws or higher taxes on alcohol are not in the common interest, and are therefore insulting. Unlike Mill, he believes that the class of these kinds of laws and restrictions is actually quite small.

Those who support public-health restrictions on individual liberty, but who wish to avoid a strong paternalist position, can do so in basically two ways. They can argue that public-health measures are only mildly paternalistic. This is the "weak paternalism" thesis (Dworkin, 1972; Feinberg). In this view, public-health measures are not strongly intrusive, and they save thousands of lives. Most philosophers today seem to embrace this view. The second and more controversial view is that public-health interventions are not at all paternalistic (Beauchamp, 1988) because the good produced is not a private or individual good, but rather a common good produced by common action. In this view, the citizen sees himself or herself as living in a world in which common action, after public and democratic discussion, often promotes public health, and while individuals may potentially benefit from these actions, the community or the common good will assuredly benefit.

The differences between these two basically supportive perspectives on most public-health legislation cannot easily be reconciled, but their differences should not be exaggerated. Both sides agree that any restriction on liberty and autonomy needs justification. The only disagreement is over who is benefiting from this restriction and whether the good is private or common.

In the public-health perspective, the conception of autonomy is one of a basic autonomy, not an absolute autonomy. A basic autonomy can be overridden on evidence that restrictions are minimal, acceptable, and will produce a substantial savings in lives. The guardians of basic autonomy are the democratic process and elected officials, such as legislators or chief executives. This makes many nervous, yet the long history of the struggle for public-health legislation is, on balance, reassuring. Because most public-health legislation necessitates the burdens placed on large numbers of individuals, including powerful interests, to benefit small numbers of individuals, the political path to successful public-health legislation is strewn with political roadblocks that are likely powerful deterrents to overzealous public-health activists. This emphasis on relying on the processes of democratic communities reflects the pragmatism of public health as philosophy, and its interest in political theory. Also, Richard Flathman, a political theorist, notes that governments rarely promote the good of a single individual (Flathman).

Public Health and Social Justice

An enduring theme in public health is the attempt to persuade democratic bodies to legislate rules for economic production and distribution that are safer and more benign. Community public-health interests frequently oppose powerful, well-organized entities such as corporations and interest groups. Public health as an interest of the community often causes deep conflict among elected officials, who are also strongly enjoined to promote economic prosperity.

The struggle for the common health and safety is further complicated by the fact that the redistribution of the burdens of health and safety protection is on behalf of "statistical lives." Thus the struggle of public health has many resemblances to the struggle for social justice in society (Beauchamp, 1976) in that they both work on behalf of the less numerous and less powerful against the power of the market and its masters. The idea of social justice influences public health, for instance, as it battles the human immunodeficiency virus (HIV) epidemic, to modify its traditional methods of fighting epidemics (Bayer), using new weapons like confidentiality and privacy to fight societal discrimination and prejudice toward the victims of the widespread epidemic.

Democracy, Public Discussion, and Public Health

Much of public health is concerned with providing and/or regulating information and education. These activities typically encounter far fewer ethical conflicts than does legislation that limits individual liberty or property in order to promote health and safety. Yet even here the distinctive footprint of public health as a social practice can be detected. Progress against cigarette smoking has been made in the United States during the decades after World War II not so much through regulating or banning smoking as through communicating the discovery by public-health researchers of the links between smoking and disease. The subsequent public discussion and controversies surrounding a series of reports by U.S. surgeons general (and also by health officials in other nations) widely publicized the links between smoking and lung cancer and heart disease. The further publicity surrounding the role of tobacco in public policy and other related controversies produced a growing awareness of smoking as a social problem. This publicity, coupled with the ban on television advertising of cigarettes, produced sharp declines in smoking rates (Warner), in advance of more recent and controversial moves to ban smoking in public areas.

Here again, the unique emphasis in public health is to use the discovery of threats to the common health as part of the "hubbub" of democracy. Such controversy can be used to affect public opinion and discussion (including a growing social disapproval of smoking) as principal forces for promoting change in individual and mass behavior (Beauchamp, 1988). Public dialogue, in turn, moves public health into the new territories of promoting more information and speech and of countering advertising's role in limiting information.

Conclusion

The idea of public health as philosophy involves the elaboration of its core ideas of promoting fallibilistic and probabilistic ways of knowing, of learning from experience and action, of imaginatively proposing new designs to social environments to promote health and safety, and, above all, of focusing on prevention and community approaches everywhere possible. While public health proponents have been successful in ensuring that their methods are central to the study of health problems, working closely with scientists studying disease from an epidemiological perspective (and in the future from a more molecular and genetic perspective), they have been less successful in having public health's group approach accepted as philosophy. While it is true that public health is one of those "second languages" of community (Bellah et al.), it has yet to be widely appreciated among philosophers and social scientists as a distinctive method with a distinctive philosophical perspective on common health problems, one that bears a strong resemblance to pragmatist perspectives on action and experience.

Finally, as health reform has increasingly dominated the public agenda in the United States, it is likely that public-health lessons will be more widely appreciated for two reasons: to prevent disease and reduce the burden and costs of illness, and, equally important, to remind the larger society that medicine and public health alike promote a common good, a lesson that is central to public health's distinguished history.

dan e. beauchamp (1995)

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