Public health — a different concept of medical ethics

Monday, while we were commemorating Memorial Day, the Health Law Institute at the University of Alberta, Canada, hosted a seminar titled: “Ethical Obesity Policy: Paternalism, Preference Change & the Good Life.” It illustrates the growing movement to eliminate the distinction between private and public health and redefine medical ethics. Governmental preventive health interventions are increasingly said to be ethically imperative for the collective good of society.

This seminar was given by professor Angus Dawson, a visiting professor from the Centre for Ethics at the University of Toronto. He is the founder of a revival of the field of “public health ethics” and the founder of a new international network and an academic journal by the same name.

Essentially, this philosophy argues that the obesity “epidemic” is such a threat to society and our quality of life, that to be moral and ethical, public health policies and preventive health must act in the name of the common good. Public interests are more important than those of individuals. The government must determine what is best for all, as individuals are incapable of protecting themselves. Society, most importantly, must act on behalf of children. Today’s public health has reached such crisis proportions, the viewpoint goes, that coercive policies that strip away individual freedoms and leave people no choice but to comply with “healthy behaviors” are now justified.

As Dr. Arya M. Sharma, M.D., head of the Canadian Obesity Network, wrote on his blog today: “Dawson's basic thesis was that when it comes to preventing obesity simply providing information does not work, some form or ‘paternalism’ (not to use the term coercion) will be required to help people change behaviours.” That’s because simply providing information on how people should behave to slim down hasn’t worked. People have no choice in today’s environment but to make bad decisions and eat “unhealthy” and drive their cars, according to this philosophy, making it necessary to take collective action for societal changes. Those societal changes are based on the myth that obesity and diversity of body size is a matter of diet and exercise.

“Getting the majority to change their behaviour is unlikely to happen without some form of paternalism, which raises the ethical dilemma of how much individual ‘freedom’ society as a whole is willing to sacrifice for the common good,” wrote Dr. Sharma.

Professor Dawson’s talk was a repeat of the one he gave at the International Society of Behavioral Nutrition and Physical Activity annual conference held this past weekend in Alberta and sponsored by the Canadian Obesity Network. According to the symposium abstract, its focus was aimed at addressing obesity by intervening in lifestyles and changing people’s behaviors — eating and physical activity. As professor Dawson argued:

[G]iven the nature of obesity, we need to employ the resources of public health ethics, rather than medical ethics, to formulate a relevant and coherent ethical framework for policy. Contemporary discussions assume that autonomy is the key ethical principle in policy formation: as a result they focus on the provision of neutral information to consumers with the intention of increasing the likelihood of individuals making informed choices about their lifestyles. However,... if we are serious about tackling obesity this approach will fail, as it, wrongly, assumes... that we ought to respect an individual's existing preferences... an alternative policy (given the relevant facts about the nature and causes of obesity) is proposed. This alternative argues that ethical obesity policy ought to focus on collective interventions, brought about through changes to regulations and features of the environment... individuals will not be able to opt out. The objection that this is unethical because it is paternalistic and imposes a certain view of the good life is rejected.

Conclusions: Obesity policy should prioritise seeking to change people's existing preferences and norms (or influencing the creation of new ones) not the promotion of autonomy.

The take home message from the Thursday session at this international symposium is that allowing individual freedoms and lifestyle choices is unethical and no longer “morally neutral,” given the “severity of the problem.”

This surely scares the willies out of everyone who remembers history.

Your body belongs to the nation! Your body belongs to the Führer!
You have the duty to be healthy! Food is not a private matter!
(German National Socialist slogan, 1937 - 1944)

Dr. James Gault comments at MDredux.