Tag Archives: public health

Soft Paternalism & Obesity Prevention

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In Holm’s article “Obesity Interventions and Ethics” he discusses whether or not it is appropriate to have public health policies that intervene to promote a person’s health. In this essay, Holm’s focuses on obesity interventions as the public health issue. Holm states that there are two main problems with this are when and if it is actually justifiable to have such policies that intervene in order to promote someone’s health and if it justifiable to have policies that can negatively affect people but benefits the common good.

Public health policies always have a paternalistic side to them, it’s just a matter of how much paternalism a policy wants to utilize. Holm’s defines three different forms of paternalism including hard paternalism, soft paternalism and maternalism (392). All three forms use different methods, to achieve a certain end. Soft paternalism, which includes “providing unwanted information or foreclosing some options for action”, should be utilized in public health policy (Holm, 392). In this way a specific decision is not forced onto a person, however they are given the information to make better (and maybe easier) decisions about maintaining their health. Some of these policies include changing food labels and changing advertising methods.

Recently the FDA has suggested new changes to food labels in order “to bring attention to calories and serving sizes” which are important in addressing problems related to obesity. Changes include writing calories in a larger font, adjusting amount per serving, and updating the necessary daily values for various nutrients and vitamins (United States). Here is a picture of the differences between our current food labels (right) and the suggested future one (left).

UpdatedLabelLabel

The main goal of these changes is to “make people aware of what they are eating and give them the tools to make healthy dietary choices throughout the day” (United States). Changing food labels will just help people become more aware of what they are eating. Even though the label may be providing “unwanted information” people can still choose to disregard the information therefore it would benefit the common good without negatively affecting people (392).

Chile has also recently changed their food labels to be more representative of the foods contents. The Law of Food Labeling and Advertising was passed in July 2012 and focuses on regulating and labeling critical nutrients, adding warning messages to foods and reducing the amount of food marketing toward children (Corvalán, Reyes, Garmendia, Uauy, 2013).  Chile is still surveying their new changes and augmenting them, however the ideas that they suggested fall under soft paternalism. If the policies prove successful, they could be utilized in United States obesity prevention efforts.

Children are group that is often referenced in paternalism debates. The same is true in regards to obesity prevention. Children are bombarded with food advertisements while watching television, which can increase their consumption of such foods. Andreyeva found that “Exposure to 100 incremental TV ads for sugar-sweetened carbonated soft drinks during 2002–2004 was associated with a 9.4% rise in children’s consumption of soft drinks in 2004. The same increase in exposure to fast food advertising was associated with a 1.1% rise in children’s consumption of fast food” (2011). The increased associated risk may seem small, but you have to think about the number of children that it is affecting and the long-term effects of this exposure. A 2008 study found that the amount of fat on a child directly increased with fast food advertising exposure (Andreyeva, Kelly, Harris, 2011). The same study suggests that reducing the amount of exposure could reduce adiposity by 18% (Andreyeva, Kelly, Harris, 2011The evidence provided suggests that merely reducing the amount of fast food commercials directed at kids could help maintain their current and future health.

All of the solutions that I have suggested have scientific evidence behind it, and have been implemented. The policies also maintain their paternalistic roots allowing no negative consequences to be forced on anyone but simultaneously is improving the health of the general public.

Sources:

Andreyeva, T., Kelly, I.R., Harris, & J.L. (2011). Exposure to food advertising on television: Associations with children’s fast food and soft drink consumption and obesity. Elsevier, 9(30): 221-233. http://dx.doi.org/10.1016/j.ehb.2011.02.004

Coravalán, C., Reyes, M., Garmendia, M.L., & Uauy, R. (2013). Structural responses to the obesity and non-communicable diseases epidemic: the Law of Food Labeling and Advertising. Obesity Reviews, 14(2): 79-87. Doi: 10.1111/obr.12099.

Holm,S. Arguing about Bioethics. Ed. Stephen Holland. Routledge: New York, NY, 2012. Print.

United States. U.S. Food and Drug Administration. Nutrition Facts Label: Proposed Changes Aim to Better Inform Food Choices. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm387114.htm#different.

 

 

 

 

 

The “When” of Libertarian Paternalism

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The reading on “Libertarian Paternalism” takes a concept that has for years been seen in a negative light and gives it a positive spin (Thaler and Sunstein). When discussing the history of health care and public health in America especially, the concept of paternalism is typically thrown around in tones of disgust and shame. Authority figures in the realm of health aren’t qualified to decide what is best for us—only we are capable of making those decisions.

In our discussions surrounding informed consent and autonomy, we continuously mulled over whether or not health care professionals have the right to make decisions or even narrow down treatment options for patients. I have come to the conclusion that they largely do have this authority and duty. Though the model of the doctor/patient relationship could use some serious work, patients do not need to know about each option available to them; being informed is important, but doctors are capable of narrowing down treatment options without full patient partnership.

Thaler and Sunstein take this question of the morality of paternalism to a different level. They use examples of a less immediate nature such as retirement plans and cafeteria layouts to illustrate the unavoidable nature of paternalism and just how beneficial it can be, suggesting that we not focus on whether or not paternalism is right in certain cases but how to choose the best paternalistic options.

Though the examples they use are simple, I believe Thaler and Sunstein have a point regarding paternalism in public health. People will most often do what is best for themselves. Public health is the improvement and maintenance of the health of communities, not the individual—thus it is not beneficial to rely upon individuals to make effective decisions in public health.

What is interesting to me, though, is that this argument can then stand as a counterargument in the informed consent and autonomy debate. If individuals do what is in their own interests, isn’t it then moral to leave health care decisions fully up to them? It would seem that if one asked Thaler and Sunstein, the answer would be yes. However, although I am convinced of their argument for paternalism in public health, I believe libertarian paternalism can also be applied to treatment decisions in health care.

Individuals are—to an extent—capable of deciding what is best for them; but in the realm of health care, there is a lot of knowledge that professionals have access to that the average person does not. Even with thorough information—it is difficult for patients to make these sometimes life altering decisions. What is so wrong with a little libertarian paternalism? As Thaler and Sunstein mention in their essay, in everyday situations in which this type of paternalism is used, it is because the people do not want to undergo the hassle of making an initial decision themselves, or they feel as though they are not specialized enough in the matter to make the appropriate decision on their own.

Though I have never before viewed paternalism positively, I believe this essay makes a sound argument for it. This does not mean that paternalism is good; it just means that there are several situations in which it is conducive to efficiency and genuine well-being which should make it acceptable.

Thaler, Richard H., and Cass R. Sunstein. “Libertarian Paternalism.” Arguing About Bioethics (2003): loc.  10829-10968. Print.

The Weight of Paternalism on the Public Health Scale

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In Public Health Law In an Age of Terrorism: Rethinking Individual Rights and Common Goods, Gostin examines public health law and the deficiencies associated with the current policies. He claims that there has been little emphasis on modernizing the laws to accommodate the recent advances in public health and constitutional law (Gostin 374). “Reform of public health law is essential to ensure that public health agencies have clear missions and functions, stable sources of financing, adequate powers to avert or manage health threats, and restrains on powers to maintain respect for personal rights and liberties” (Gostin 374-375).

During his argument, he challenges critic’s concerns about personal libertarianism and the protection of personal rights in the event of a national wide medical emergency.  For Gostin, compulsory power is necessary for public health because the government has the right to prevent individuals from endangering others. “The state undoubtedly needs a certain amount of authority to protect the public’s health” (Gostin 381). This action obviously compromises the individual’s autonomy in certain situations and creates moral concerns for authorities.

In addition to his argument, I think it’s important for critics to recognize how these policies come into play and who writes them. As Americans, we have the civil liberty to vote for policy makers, state representatives and even the passage of certain laws. While the individual’s current right may be undermined at the time of an emergency, they have the capacity to exercise their personal liberty in voting for state representatives and legislative officials.

You cannot remove paternalism from public health. As Thaler and Sunstein have pointed out, “some kind of paternalism is likely whenever such institutions set out arrangements that will prevail unless people affirmatively choose otherwise” (Thaler and Sunstein 390). The public voted for such regulations and must comply with them accordingly. In the realm of public health policy we often forget where the law initially stems from. It’s the people.

As citizens, we have the ability to exercise our autonomy towards choosing which paternalistic approach we like the most; perhaps it’s the one that promotes the most personal freedom. Regardless of the policy outcome, paternalism and public health go hand in hand.

Sources:

Thaler, Richard H., Sunstein, Cass R. “Behavioral Economics, Public Policy, and Paternalism: Libertarian Paternalism.” Arguing About Bioethics. London: Routledge, 2012. 386-391. Print.

Gostin, L.O. “Public Health Law in an Age of Terrorism: Rethinking Individual Rights and Common Goods.” Arguing About Bioethics. London: Routledge, 2012. 374-384. Print.

Public Health and Respect for Personal Autonomy

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Applying ethical principles to the medical field has proven complex, as highlighted by James Childress in his writings on the complexities of adhering to respect for personal autonomy.[1] The philosophical discipline of bioethics is not narrowly tied to medicine, but expands to cover medical anthropology, medical sociology, health politics, health economics, research, public health policy, and more.[2] Public health aims at improving the health of the community as a whole, and public health initiatives usually involve preventative measures that prolong life and promote health. Generally, public health policy concerns itself with health based on population-level health analysis.  Thus, how do ethical principles change when the policy is focused on net benefit for the community, instead of focusing on individual community members?

Concentration on the group needs and health leads to thinking that often forgets about individual rights, but ethical principles of the individual need to be remembered when applying public health policies. Historically, individual rights are becoming increasingly recognized, and in the medical field, consent is a twentieth-century phenomenon.[3] As medicine increasingly recognizes individual rights, it is a logical extension for public health as a discipline to acknowledge analogous rights.

In bioethics, consent is rooted in the ethical principle of respect for personal autonomy, but this principle is complex and limited in application. Childress in “The Place of Autonomy in Bioethics” presents the scope of applicability of the principle of autonomy in medicine. He argues that first and foremost respect for autonomy of persons differs from people who are not autonomous such as children (unspecified age range) and the insane. Also, respect for autonomy must coincide with other necessary ethical principles such as beneficence and care, and in certain circumstances, ethical principles can outweigh or override one another. Thus, under certain circumstances the principle of respect for personal autonomy may be infringed upon, and specifically, the realm of public health needs to consider if policies made for the benefit of the group reasonably infringe upon the personal autonomy of group members.

The political cartoon depicts the modern-day anti-vacccination “epidemic.” This so-called epidemic is happening parallel to increasing focus on individual rights. Our generation will have to consider how much public health can infringe upon personal autonomy of our society’s citizens. (Source: http://theweek.com/cartoons/index/228275/the-anti-vaccine-epidemic)

This past September, 750 students in Winston-Salem, NC faced suspension after not adhering to state vaccination policies for the Tdap vaccination that protects against tetanus, diphtheria and whooping cough or pertussis.[4] Cases of mandatory vaccinations represent paternalistic interventions where interference with an individual’s liberty may be justified by reasons such as welfare, happiness, values, interests, and needs of the person being coerced. Mandatory vaccination initiatives are public heath measures that override rights of respect for personal autonomy for the sake of containing and preventing infection and disease. In context to this case, paternalism functions off the principle of beneficence. Mandatory vaccinations highlight the conflicts between moral principles, and under these circumstances, I think beneficence overrides each group member’s autonomy. While privacy and confidentiality can still be protected, controlling the spread of disease and preventing illness in community members is a moral call to action for vaccination. While it may be easier to fully respect the autonomy of an individual patient than an entire population, public health policy still should not deprive individuals of their rights without thoughtful consideration. Following Childress’s logic, are all group members considered equally autonomous thus infringement upon personal autonomy is the same? Or, based on group status does infringement on personal autonomy have different implications? In modern times, awareness of personal rights is increasing within bounds; therefore, it is important for public health to grasp and debate these ethical concerns. A new interpretation could view mandatory consent as a prior consent based on group membership, and thus interference is the price of group membership.[5]  Such a viewpoint believes that the individual’s interests are still considered, but an individual is accepting his or her role as a group member. Future public health policies could work to understand the line between respect for personal autonomy and social responsibility, and from there, public health can define its realm of action and control.

Sources:

[1] Childress, J. F. “The Place of Autonomy in Bioethics”

[2] Benatar, D. Bioethics and health and human rights: a critical view. Journal of Medical Ethics. 2006 January; 32(1): 17-20. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563274/

[3] Veatch, R. M. “Abandoning Informed Consent”

[4] http://www.journalnow.com/news/local/article_b770c0ca-2484-11e3-93a9-001a4bcf6878.html

[5] Hall, Spencer. Should public health respect autonomy? Journal of Medical Ethics. 1992. 18: 197-201.