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The Evolution of Classical The Evolution of Classical Liberalism and Liberalism and Public Health Ethics Public Health Ethics Thaddeus M. Pope, J.D., Ph.D. Thaddeus M. Pope, J.D., Ph.D. January 24, 2005 January 24, 2005

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Page 1: The Evolution of Classical Liberalism and Public Health Ethicsthaddeuspope.com/images/Pope_-_Public_Health_Ethics.pdf · The Evolution of Classical Liberalism and Public Health Ethics

The Evolution of Classical The Evolution of Classical Liberalism and Liberalism and Public Health EthicsPublic Health Ethics

Thaddeus M. Pope, J.D., Ph.D.Thaddeus M. Pope, J.D., Ph.D.January 24, 2005January 24, 2005

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Bioethics Framework

New Framework

Public health ethics

� ��

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�� Public health issues are increasingly Public health issues are increasingly behavioral in nature.behavioral in nature.

�� There are two main frameworks for analyzing There are two main frameworks for analyzing behavioral restrictions.behavioral restrictions.

�� The communitarian framework is unnecessary.The communitarian framework is unnecessary.

�� The communitarian framework cannot account The communitarian framework cannot account for voluntarily assumed risks.for voluntarily assumed risks.

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�� Obesity and dietObesity and diet�� TobaccoTobacco�� Unsafe sex Unsafe sex �� Seatbelt useSeatbelt use�� Illicit drug useIllicit drug use

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�� LiberalismLiberalism

�� CommunitarianismCommunitarianism

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�� Presumption in favor of autonomyPresumption in favor of autonomy

�� LibertyLiberty--limiting principleslimiting principles

Harm to others Harm to others Harm principle Harm principle Harm to self Harm to self PaternalismPaternalismHarm to community Harm to community Harm principle?Harm principle?

MoralismMoralism??

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�� Early proponentsEarly proponents�� Dan E. Beauchamp (1976 Dan E. Beauchamp (1976 et seq.et seq.))�� Marc Marc LappeLappe (1986)(1986)

�� Recent proponentsRecent proponents�� Larry Larry GostinGostin (2000 (2000 et seq.et seq.))�� AmitaiAmitai EtzioniEtzioni (2002)(2002)

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�� NoNo presumption in favor of presumption in favor of autonomyautonomy

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�� No distinct liberty limiting principlesNo distinct liberty limiting principles

Harm to self Harm to self Public healthPublic healthHarm to others Harm to others Public healthPublic healthHarm to community Harm to community Public healthPublic health

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Liberalism lacks a population-level liberty limiting principle.

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�� The liberal framework The liberal framework doesdoes need a need a ““collective goodcollective good”” liberty limiting principleliberty limiting principle

�� But why not just add a new principle, But why not just add a new principle, rather than change the whole framework?rather than change the whole framework?

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Liberalism Liberalism ““fitsfits”” better with our better with our postpost--1960s individualistic 1960s individualistic tradition.tradition.

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Liberalism Liberalism ““fitsfits”” better with tradition.better with tradition.

andand

It It cancan handle public health ethics.handle public health ethics.

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�� The The ““collective goodcollective good”” libertyliberty--limiting limiting principle principle

�� Positive or negative Positive or negative �� HarmHarm�� CollectiveCollective

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�� Public health concerns what we do Public health concerns what we do collectivelycollectively

�� SocietallySocietally organizedorganized�� Measures aimed at the population Measures aimed at the population �� Beyond individual controlBeyond individual control

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BUT BUT Not all public health concerns Not all public health concerns ““collectivecollective”” issues.issues.

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�� If the risk is under individual control, If the risk is under individual control, then it affects only then it affects only somesome parts of the parts of the communitycommunity

�� Using motorcycle helmetsUsing motorcycle helmets�� Diet?Diet?

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�� The people who make up the community The people who make up the community have a have a shared valueshared value in public health. But in public health. But otherwise have otherwise have different ideasdifferent ideas of the good of the good life. life.

---- D. Beauchamp & D. Beauchamp & SteinbockSteinbock (1999)(1999)

�� ““Many publicsMany publics””---- Wendy Wendy ParmetParmet (2003)(2003)

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PluralismPluralism

–– We all have different values.We all have different values.–– Who determines what is Who determines what is

benefit?benefit?

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�� CommunitarianismCommunitarianism should not should not ““maskmask””paternalism.paternalism.

�� CommunitarianismCommunitarianism should abide by its should abide by its ““fairnessfairness”” criteria.criteria.

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Counterargument # 1:Counterargument # 1:

–– The The aggregateaggregate effects of individual effects of individual choices affects public healthchoices affects public health

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Counterargument # 2:Counterargument # 2:

–– Behavioral risks are Behavioral risks are notnotsubstantially voluntarily assumedsubstantially voluntarily assumed

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My responseMy response::

�� Develop the empirical evidenceDevelop the empirical evidence

�� Even if Even if voluntarinessvoluntariness is impaired, is impaired, much conduct is still much conduct is still substantiallysubstantiallyvoluntaryvoluntary

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�� Liberalism should be the framework for Liberalism should be the framework for public health ethics.public health ethics.

�� Liberalism must Liberalism must evolveevolve to address the to address the conditions under which liberty can be conditions under which liberty can be limited for collective goods.limited for collective goods.

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Thaddeus M. PopeThaddeus M. PopeArnold & Porter LLPArnold & Porter LLP

777 South Figueroa St., 44777 South Figueroa St., 44thth FloorFloorLos Angeles, CA 90017Los Angeles, CA 90017

TEL 213TEL [email protected][email protected]

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I.I. LiberalismLiberalismII.II. CommunitarianismCommunitarianismIII.III. Public health ethicsPublic health ethics

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&��������������"��&��������������"��

I. Liberalism–– Jeremy Jeremy BenthamBentham, The Principle of Morals and , The Principle of Morals and

Legislation Legislation chch. XVI & IX (1781).. XVI & IX (1781).–– Richard A. Epstein, Richard A. Epstein, Let the Shoemaker Stick to His Let the Shoemaker Stick to His

Last: A Defense of the Last: A Defense of the ““OldOld”” Public Health, Public Health, 46 46 Perspectives Biol. & Med. S138Perspectives Biol. & Med. S138--S159 (2003).S159 (2003).

–– Richard A. Epstein, Richard A. Epstein, In Defense of the In Defense of the ““OldOld”” Public Public Health, Health, 69 Brook. L. Rev. 1421 (2004).69 Brook. L. Rev. 1421 (2004).

–– Joel Feinberg, Harm to Others (1984).Joel Feinberg, Harm to Others (1984).

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I. Liberalism–– Thaddeus M. Pope, Thaddeus M. Pope, Balancing Public Health against Balancing Public Health against

Individual Liberty: The Ethics of Smoking Individual Liberty: The Ethics of Smoking Regulations, Regulations, 61 U. Pitt. L. Rev. 41961 U. Pitt. L. Rev. 419--92 (2000).92 (2000).

–– Andrew Siegel, Andrew Siegel, Jurisprudence of Public Health: Jurisprudence of Public Health: Reflections on Lawrence O. Reflections on Lawrence O. GostinGostin’’ss Public Health Public Health Law, Law, 18 J. 18 J. ContempContemp. Health L. & . Health L. & PolPol’’yy 359 (2001).359 (2001).

–– Dennis F. Thompson, Dennis F. Thompson, Paternalistic Power, in Paternalistic Power, in Political Ethics and Public Office 148Political Ethics and Public Office 148--77 (1987).77 (1987).

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II. Communitarianism– Dan E. Beauchamp, Public Health and Individual

Liberty, 1980 Ann. Rev. Pub. Health 121-36 (1980).

– Dan E. Beauchamp, Community: The Neglected Tradition of Public Health, Hastings Center Rep., Dec. 1986, at 28.

– Dan E. Beauchamp, Injury, Community, and the Republic, 17 L. Med. & Health Care 42 (1989).

– Dan E. Beauchamp & Bonnie Steinbock, New Ethics for the Public Health (1999).

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II. Communitarianism– Amatai Etzioni, Public Health Law: A

Communitarian Perspective, 21 Health Affairs 102-04 (Nov./Dec. 2002).

– Lawrence O. Gostin, When Terrorism Threatens Health: How Far Are Limitations on Personal and Economic Liberties Justified? 55 Fla. L. Rev. 1105 (2003).

– Lawrence O. Gostin, Law and Ethics in Population Health, 28 Austr. & N.Z. J. Pub. Health (2004).

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III. Public Health Ethics–– Dan Callahan & Bruce Jennings, Dan Callahan & Bruce Jennings, Ethics and Public Ethics and Public

Health: Forging a Strong RelationshipHealth: Forging a Strong Relationship, 92 Am. J. , 92 Am. J. Pub. Health 169 (2002).Pub. Health 169 (2002).

–– J.F. Childress & R.G. J.F. Childress & R.G. BernheimBernheim, , Beyond the Liberal Beyond the Liberal and Communitarian Impasse: A Framework and and Communitarian Impasse: A Framework and Vision for Public HealthVision for Public Health, 55 Fla. L. Rev. 1191 (2003)., 55 Fla. L. Rev. 1191 (2003).

–– Nancy Nancy KassKass, , Public Health Ethics: From Public Health Ethics: From Foundations and Frameworks to Justice, Foundations and Frameworks to Justice, 32 J. L. 32 J. L. Med. & Ethics 232Med. & Ethics 232--42 (2004).42 (2004).

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III. Public Health Ethics–– S.R. S.R. LeederLeeder, , Ethics in Public Health, Ethics in Public Health, 34 Int. Med. J. 34 Int. Med. J.

435435--39 (2004).39 (2004).–– Wendy Wendy ParmetParmet, , Liberalism, Liberalism, CommunitarianismCommunitarianism, and , and

Public Health, Public Health, 55 Fla. L. Rev. 1221 (2003).55 Fla. L. Rev. 1221 (2003).