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A balanced intervention ladder: promoting autonomy through public health action
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Available online at www.sciencedirect.com
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Mini-Symposium
A balanced intervention ladder: promoting autonomy through public health action P.E. Griffiths*, C. West Department of Philosophy, University of Sydney, NSW 2006, Australia
article info
abstract
Article history:
The widely cited Nuffield Council on Bioethics ‘Intervention Ladder’ structurally embodies
Received 16 November 2014
the assumption that personal autonomy is maximized by non-intervention. Consequently,
Received in revised form
the Intervention Ladder encourages an extreme ‘negative liberty’ view of autonomy. Yet
3 August 2015
there are several alternative accounts of autonomy that are both arguably superior as
Accepted 19 August 2015
accounts of autonomy and better suited to the issues facing public health ethics. We
Available online 29 August 2015
propose to replace the one-sided ladder, which has any intervention coming at a cost to autonomy, with a two-sided ‘Balanced Intervention Ladder,’ where intervention can either
Keywords:
enhance or diminish autonomy. We show that not only the alternative, richer accounts of
Nuffield council on bioethics
autonomy but even Mill's classic version of negative liberty puts some interventions on the
Intervention ladder
positive side of the ladder.
Public health ethics
Crown Copyright © 2015 Published by Elsevier Ltd on behalf of The Royal Society for Public
Nanny state
Health. All rights reserved.
John Stuart Mill
Public health ethics and the intervention ladder The 2007 Nuffield Council on Bioethics report Public health: ethical issues1 is a foundational document in the field of public health ethics. It was the subject of the opening editorial in the first issue of the journal Public Health Ethics2 and continues to be widely cited in that and cognate journals. Many of these authors take issue with elements of the report, as we do here, but it remains a key point of reference even for its critics. The Nuffield report developed a framework for justifying state interventions that cannot easily be justified within conventional liberal political theory because of John Stuart Mill's ‘harm principle’3: the state should not interfere with people's choices unless they cause harm to others. This principle can
be defended on both instrumentalist and intrinsic grounds. Instrumentally, Mill argued that individuals are the best judges of what is in their own interest. But he also suggested that the very purpose of our social institutions is, or should be, the promotion of individual liberty in the sense of reflective self-determination.3 So minimizing state interference is intrinsically desirable. The Nuffield report introduces an additional set of ethical considerations that need to be balanced against individual liberty. The ‘Stewardship model’ proposes that the state has a duty to enable its citizens to achieve good health. The report suggests that good stewardship will often conflict with the promotion of individual liberty. In that case, the cost to liberty needs to be balanced against the benefit to public health. The ‘intervention ladder’
* Corresponding author. Tel.: þ61 2 9351 7027. E-mail address: [email protected] (P.E. Griffiths). http://dx.doi.org/10.1016/j.puhe.2015.08.007 0033-3506/Crown Copyright © 2015 Published by Elsevier Ltd on behalf of The Royal Society for Public Health. All rights reserved.
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(Fig. 1) is a proposed framework for balancing these two considerations. There is much to admire in the Nuffield Council's report. However, many of the subtleties in the report are of necessity omitted from the intervention ladder. This matters, because the report is not intended merely for academic consumption. The intervention ladder is an important tool in communicating the report's conclusions to a wider audience, including policy makers. For example, the intervention ladder features prominently in an illustrated colour brochure Public health: ethical issues a guide to the report, issued alongside the main document and intended to summarize its conclusions. Our concern in this paper is with a structural feature of the ladder. The vertical axis of the ladder represents the increasing cost to liberty, and non-intervention is at the bottom. It is an immediate consequence of this structure that no policy can do more to promote liberty than non-intervention. Moreover, any action by the state, even the provision of information, imposes some cost to liberty. Subtler views can be found in the body of the report (see, for example, Sections 2.36 & 2.38), but this very unsubtle view is inescapably expressed in the main visual tool used to disseminate the report's findings.
Theories of freedom and autonomy The Intervention Ladder embodies a conception of freedom that can be termed negative, liberal, or libertarian and which
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equates autonomy with non-interference. On this conception, any intervention designed to promote public health necessarily comes at a cost to individual autonomy; and, consequently, stands in need of justification. This non-interference conception of autonomy means that the burden of proof is placed on public health advocates to demonstrate that the welfare benefits of any proposed intervention outweigh the costs to individual liberty. However, the philosophical literature offers numerous alternative accounts of autonomy. Many of these alternate accounts would not assume that public health initiatives automatically compromise autonomy. Interventions may sometimes enhance individual autonomy, and even sometimes be required for it. With these alternative accounts, we need not view public health interventions as necessarily posing a trade-off between freedom and other values (e.g. welfare). In this section and the next we provide a taxonomy of philosophical theories of freedom and autonomy, giving a sense of the place of the non-interference conception within this much wider territory. We argue that the traditional libertarian conception is impoverished; and go on to make a case for the superiority of a positive account of individual freedom or autonomy. Specifically, a better account of autonomy is provided by the positive accounts that include a reflective endorsement condition; we provide a discussion of what is meant by reflective endorsement. Such positive accounts of autonomy are compatible with the promotion of public health
Fig. 1 e The Intervention Ladder (numbers added by authors). ‘The range of options available to government and policy makers can be thought of as a ladder of interventions, with progressive steps from individual freedom and responsibility towards state intervention as one moves up the ladder. In considering which ‘rung’ is appropriate for a particular public health goal, the benefits to individuals and society should be weighed against the erosion of individual freedom. Economic costs and benefits would need be taken into account alongside health and societal benefits.’1
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measures; more strikingly still, an implication of these accounts is that some of the measures that restrict freedom on the libertarian model, actually enhance autonomy. In the latter part of this paper we propose a revised version of the ladder that incorporates this feature. The exact form of a revised ladder would, naturally, depend on what specific conception of autonomy is adopted. Our basic proposal, that the ladder requires a positive side to balance it, requires only a slightly more sophisticated version of negative liberty: as we will see shortly, the materials can be found in Mill's own account. The richer, alternative accounts of autonomy that we consider allow a wider range of actions to be identified as enhancing autonomy.
Freedom as non-interference: the libertarian conception The negative account of individual freedom finds its classic expression in John Stuart Mill's On Liberty. Mill is primarily concerned with self-determination: the ability to decide for yourself how to live your life. He writes, ‘[t]he only freedom which deserves the name is that of pursuing our own good in our own way, so long as we do not attempt to deprive others of theirs, or impede their efforts to obtain it.’3 An individual is free just so long as she is not prevented, by external or internal constraints, from acting on her desires. For Mill, external threats to freedom can take several forms: formal legal prohibitions and punishments, or informal social pressures to conform to established norms or sanctioned ways of life. Mill categorized the latter as ‘social coercion’, in contrast with legal coercion. In The Subjection of Women Mill displays sensitivity to the way in which individual autonomy can be compromised by the internalization of oppressive social norms that renders individuals ‘willing slaves’, invisibly bound to a mode of life that they would not choose under more idealdi.e. better factually informed, less restrictivedconditions.4 Mill famously insists that the only legitimate reason for coercive interference with individual liberty is in order to prevent harm to third parties. On Liberty begins with a wellknown statement of what has come to be known as the ‘harm principle’: ‘[T]he only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others.’3 Mill holds that neither the state nor any individual or smaller collective is ever justified in coercively interfering with a person's freedom simply for his or her own good. So far we see how these elements of Mill are consistent with the conception of autonomy embodied in the Intervention Ladder; yet Mill's position, in contrast to the Ladder, would not endorse the assumption of an automatic cost to liberty through the introduction of public health measures e for he takes intervention by so-called non-coercive means to be entirely consistent with individual liberty. Thus it is entirely legitimate to attempt to deter an individual from making ‘bad’ or imprudent choices by ‘remonstrating with him, or reasoning with him, or persuading him, or entreating him.’3 Consequently there is nothing in Mill's harm principle that assigns a cost in liberty to public education campaigns designed to inform or persuade consumers of the dangers of smoking or the merits of consuming more fruit and
vegetables; and, indeed, Mill asserts that a precondition for autonomous deliberation is foreknowledge of the likely consequences of one's choices and actions. Mill states explicitly that the harm principle is supposed to apply only to ‘human beings in the maturity of their faculties.’3 Thus even more paternalistic measures may be justified in dealings with children, and with adults whose decision-making capacities are temporarily or permanently impaired (e.g. through drunkenness, illness or mental incapacity); again with no cost to liberty. It would therefore be entirely consistent with the harm principle to, for instance, place restrictions on advertising directed at children in order to protect them from harming themselves. By placing the provision of information at one and regulation (including, presumably, restrictions on corporate marketing to children) at six, the Nuffield Ladder implies that such measures must come at a price to liberty. The only way to justify the assumption that the provision of information contingently comes at a cost to individual liberty is to further assume that people, as a matter of fact, do not want to be informed; but this assumption too appears unjustified. The provision of information should instead be represented as an intervention that enhances autonomy. The Nuffield Report proper recognizes these richer aspects of Mill's position (see, for example, Sections 2.36 & 2.38); yet the vision represented in the Nuffield Ladder is impoverished, neglecting these important aspects of Mill's account, as discussed above. The Ladder assumes that any intervention comes at a cost to liberty; Mill does not.
Nudging In an influential amendment to the libertarian position Cass Sunstein and Richard Thaler have defended a position they dub ‘libertarian paternalism,’ arguing that paternalistic ‘nudging’ is compatible with respect for libertarian freedom.5 ‘Nudging’ involves the deliberate attempt to steer individuals towards making choices that are likely to promote their own ends by fiddling with ‘choice architecture’ (the environment in which choices are made). The case for nudging starts from well-known behavioural research findings that undermine the factual presuppositions of Mill's instrumental argument against paternalism. Individuals are not rational actors who always act so as to maximize expected utility, but are prone systematically to make certain errors in pursuing their own good. One might worry that nudging is unjustifiably manipulative, since it depends on influencing individuals' choices in ways that individuals themselves are not consciously aware of and have not specifically consented to; but the foundation of Sunstein's argument is that our choices are inevitably influenced in some direction by the ‘choice environment’, and that we are commonly not conscious of this influence; the environment in which the citizen is free from all influence is a fiction; the only questions, then, are those concerning who influences our choices, how they do it, how aware are we of their intervention, and what are the ultimate effects of their influence. Moreover, it is plausible that, upon becoming informed about their own rational limitations, individuals would consent to ‘manipulation’ that serves their own desired goals, just as some individuals voluntary avail themselves of
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hypnotism and other subconscious mechanisms in attempts to give up smoking.6 In earlier work, one of us has argued that manipulation of this kind need not compromise autonomy if the individual gives consent to the process.7
Freedom as non-domination: the republican conception Philip Pettit has developed and defended an influential alternative negative conception of freedom. Pettit calls this the republican conception of freedom.8 The implications of this work for public health ethics have been explored by several authors.9e11 The libertarian or ‘neo-liberal’ conception contrasts freedom with constraint or interference, whereas on the republican conception the antonym of freedom is domination. Imagine a slave who is fortunate enough to have a benign mistress who lets him do whatever he wishes.8 This slave would be free on the liberal conception, since no one actually interferes with his choices, but he would be unfree on the republican conception, since he is a slave. More precisely, the fact that his mistress could interfere with his choices if she chose to, is sufficient to render him unfreedeven if she never actually interferes, and even if the probability that she will interfere is very low. Freedom, on Pettit's republican conception, equates to this kind of counterfactually robust or resilient non-interference. The republican conception of freedom remains a negative conception insofar as its chief focus remains on interference, but it differs from the libertarian or ‘neo-liberal’ account in implying that intervention need not be inimical to individual freedom, and may in fact be necessary for it. Without the protections afforded by a democratic constitution, for instance, individual members of a society cannot be free, no matter how much non-interference they happen to enjoy. In the context of this article, we note that the disproportionate power wielded by corporations to constrain and dictate the options available to ordinary consumers can be viewed as posing a very substantial threat to individual freedom, a threat from which individuals may have a freedom-based claim for protection. The example of the slave with the benign mistress is designed to show that (actual) non-interference is not sufficient for freedom. The interference of the sailors who bind Ulysses to the mast so as to enable him to resist the call of the Sirens is designed to show that non-interference is not necessary for freedom either. When the sailors bind Ulysses to the mast so as to enable him to resist the call of the Sirens, they constrain his actions, but not his freedom; for, in so binding him, they are acting in accordance with his expressed and considered wishes. Many of us are familiar with using less drastic devices of this kind to ‘bind’ ourselves into a desired pattern of healthy behaviour, whether by hiring a personal trainer or by the cheaper expedient of not buying the cookies we know we will want that evening.
Positive freedom and autonomy Negative neo-liberal and republican conceptions of freedom contrast with ‘positive’ conceptions, according to which freedom requires not merely the absence of constraints but
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also sufficient power and resourcesdmaterial, social and psychologicaldto pursue one's own ends effectively.12 Positive accounts of freedom regard non-interferencedeven resilient non-interferencedas insufficient; by these accounts, freedom requires skills and substantive opportunities that do not exist de novo, but must be enabled through education and other social goods. Autonomy is not something that individuals have by default, just so long as no one interferes with them. Making free and rational decisions about how to lead one's life, and then acting on them, requires information, imagination, critical reasoning abilities, literacy and numeracy skills and personal attributes (self-confidence, courage, forbearance, self-control), which can exist only with the appropriate social and institutional protections and supports. It also requires independence from internal and external sources of domination and control. Concern for individual autonomy may therefore justify interventions that foster these abilities and conditions.
Reflective endorsement The terms ‘freedom’ and ‘autonomy’ are sometimes used interchangeably; however, in many philosophical discussions, freedom is distinguished from autonomy in that the former is taken to concern constraints on an individual's ability to act on their desires, whereas autonomy concerns the independence and authenticity of an individual's desires (values, etc.) in the first place.13,14 Whereas the paradigm example of an unfree individual, in this sense, is someone who is physically restricted (e.g. imprisoned), the standard example of a non-autonomous individual is the addict who is compelled by her immediate desires to take drugs against her ‘better judgement’ (different theories of autonomy single out different psychological features as making choices genuinely autonomous). The autonomous individual, by contrast, is free from such internal, as well as external, domination. Thus distinguished, it is possible to be autonomous but unfree, and to be free but non-autonomous. Importantly, for our purposes, while processes such as brainwashing, manipulation, indoctrination and the internalization of oppressive norms may not pose a threat to freedom, so understood, they clearly pose a threat to autonomy. Thus, while the role of corporations and corporate marketing in shaping and manipulating individuals' desires may not be seen to pose a threat to (negative) freedom, it poses a prima facie threat to individual autonomy. Theories of autonomy in the philosophical literature agree that autonomy cannot be equated with an individual's ability to act on her (first-order) desires, because the desires (values, emotions, etc.) on which she acts may not be ones that she would endorse or want to act on, all things considered, upon the appropriate sort of critical reflection.14,15 To illustrate this point with an example: it may well be that if one of us were properly informed about the calorific and nutritional content of a delicious-looking chocolate cookie, they would no longer want to consume it, or would cease to judge consuming it to be in their best interests, given their strong desire to maintain a healthy weight. Under these circumstances, autonomy might be enhanced, rather than diminished, by interventions that assist them to resist the allure of the cookie, in accordance with their considered wishes. Such interventions might
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include their co-author ‘binding’ their choice by removing the cookies from the office. More seriously, considerations such as these might justify restrictions on the marketing and display of unhealthy foods in retail outlets to promote the autonomy of weak-willed consumers, given a suitable mandate from those consumers.
Procedural vs. substantive approaches In the philosophical literature on autonomy this reflective endorsement model is categorized as a procedural theory, in that it includes no restriction on the content of the desires (values, etc.) in virtue of which a person can be considered autonomous. In principle, any first-order desire that an agent would endorse by a process of critical reflection counts as autonomous in virtue of being so endorsed, regardless of the content of the desires. The majority of contemporary accounts of autonomy are procedural. Substantive theories of autonomy, by contrast, reject the claim that procedural independence is sufficient for autonomy; these accounts require, in addition, that autonomous preferences have specific contents or are formed under specific social conditions.16e18 For example, a substantive theory might insist that an individual (e.g. a willing junk food addict) who embraces his unhealthy lifestyle could not be genuinely autonomous, at least with respect to that lifestyle choice, as a matter of conceptual necessity, even if, upon reflection, he subjectively endorses this lifestyle and the processes that led him to embrace it. Substantive theories of autonomy are controversial because they tie the theory of autonomy to a particular view about what constitutes a valuable human life, and therefore conflict with the popular liberal commitment to value neutrality.
Structural, historical, and relational approaches Structural theories of autonomy focus on an aspect of the structure of a person's internal psychological state at a particular moment in time, and on whether the desires (values, etc.) on which a person acts have been subject to the appropriate sort of critical reflection, regardless of the external causal and historical processes that have led to this psychological state. Mill's negative account and the positive, reflective endorsement account discussed above are both structural theories of autonomy. Structural theories, both negative and positive, contrast with historical and relational theories of autonomy; the latter attend to broader external historical and social influences on deliberation and action, and the ways in which these influences may impede, or enhance, individual autonomy. (For examples of historical theories, see.19,14 For a classic discussion of relational approaches see.20) In so doing, they seek to address a wellknown problem with purely structural accounts by accounting for the apparently autonomy-compromising impact of processes such as brainwashing, indoctrination, manipulation and oppressive socialization. The science fiction example of the evil scientist, who secretly implants a device in a subject's brain so as to control their mental states paradigmatically deprives the subject of autonomy, not by interfering with their ability to act on their desires, but by controlling the
nature of their desires in the first place. This interference seems to violate autonomy even if the scientist interferes at the level of second order desires, such as the desire not to want to smoke. Structural approaches struggle to account for this intuition because they analyse autonomy as a feature of a person's mental state at a particular moment in time, ignoring the historical processes that may have led up to that psychological state. In the present context, historical and relational considerations might suggest that the ‘marketing matrix’21,22 plays much the same role as the hypothetical evil scientist.
A balanced intervention ladder The richer perspectives on autonomy that we have reviewed in this paper are well known in contemporary ethics and moral psychology, and have been discussed in public health ethics.6,23 If they are to have any influence on public discussion and on policy, however, they will need to be formulated in a manner as appealing as the original Intervention Ladder. This is readily done by a ‘balanced’ version of the ladder, in which inaction represents zero and actions may have either positive or negative consequences for freedom (Fig. 2). At the bottom of the ladder are public health actions that substantially restrict autonomy, and at the top are public health actions that substantially enhance autonomy. Comparing the original Ladder (Fig. 1) with our balanced ladder, the reader will see that some policy actions previously shown as diminishing autonomy are now on the positive side of the ladder. The discussion above has revealed that even on classical liberal principles, these actions enhance rather than diminish autonomy. This provides an even more urgent reason to replace the one-sided ladder. In the one-sided ladder, ‘nudge’ interventions were treated as moderate infringements of autonomy. In the balanced ladder they are treated as autonomy-neutral. This is perhaps the most controversial change we have made to the ranking in the original Ladder. However, we are persuaded by the argument (see above) that default choice architecture is not neutral. The shift from a choice architecture that subrationally manipulates consumers in a way that is indifferent to their interests to one in which some manipulations are designed to advance their interests is at worst autonomyneutral. The provision of information is treated in the original Ladder as a small infringement of autonomy. But it is uncontroversial that full information is a precondition of any genuinely autonomous choice. The balanced ladder therefore places the provision of accurate, relevant information on its first positive rung, as an autonomy-enhancing intervention. There may be other costs e financial ones, for example e to balance against the health benefits of this intervention, but there are no costs to autonomy. Classical liberalism itself recognizes the role of education in allowing individuals to develop their minds in ways that allow them able to participate as free and equal members of their society. Education equips individuals to understand their options, to weigh the costs and benefits of those options effectively, and perhaps to be more resistant to attempts at
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Fig. 2 e A balanced intervention ladder. The options available to government and policy makers to improve health may either enhance (þ) or diminish (¡) autonomy. No special justification is required for interventions that simultaneously enhance health and autonomy. For autonomy diminishing interventions, the health benefits to individuals and society should be weighed against this cost. In both cases, economic costs and benefits need be taken into account alongside health costs and benefits.
sub-rational manipulation. Education of this kind is on the second rung of the balanced intervention ladder as a substantially autonomy-enhancing intervention. While this change can be justified in terms of classical liberalism, relational and historical views of autonomy would regard this as a fundamental aspect of autonomy, and would take a broader view of what might count as educating for autonomy. For example they might emphasize the need to build the individual's sense of self-worth through education, as well as their ability to weigh costs and benefits. Some public health interventions seek to mandate or incentivise the provision of healthier options for people to choose between. Because these interventions add to the choices available to people without any compensating loss of choice, they cannot reasonably be regarded as reducing autonomy and, we place them on the third rung of the positive side of our ladder. These interventions do restrict corporations, but we should not conflate the freedom of corporations with the freedom of citizens. The ability of human beings to live as autonomous agents to the fullest extent possible may be a fundamental value, but the ability of a corporation to act autonomously can surely only be defended as an instrumental value. It may be that there are costs to economic efficiency
from interventions that make healthier choices available to consumers, and that may be an argument against intervening, but not because of the cost to autonomy, even on a classical liberal conception of autonomy! Most of us need help at some point in our lives to make the choices we want to make. We may hire a personal trainer, or join a structured program to quit smoking. A good way to look at such supports is as ‘scaffolding’ that allows us to act as an autonomous individual e someone whose goals and values are reflected in their actions. Interventions that provide scaffolding of this kind, which individuals can access to help them achieve their goals, are on the fourth rung of the balanced intervention ladder as very substantially autonomyenhancing interventions. This change to the ladder probably requires a conception of autonomy that at least includes the reflective endorsement condition that we argued for above. We tentatively consider a fifth and final rung on the positive side of the intervention ladder. This involves restricting the choices available to people, rather than facilitating choice. The kind of scaffolded autonomy that forms the fourth rung will often involve an individual removing certain options from their immediate grasp, as in the classical example of Ulysses and the Sirens. But what we have in mind here is a collective
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version of Ulysses. There are choices that cannot be effectively made except at the level of the community. In some cases, these policies represent trade-offs between the freedom of different individuals. Some people might prefer the freedom to play ear-splitting music in the small hours of the morning, but their neighbours have voted for a noise restriction to defend their freedom to sleep. But in other cases, the whole community may recognize through democratic decision-making that they wish to restrict their own choices in order to live, collectively, as they truly wish to live. The decision of a remote Australian community to ban the sale of alcohol as a means to deal with family violence might represent such an example. We recognize that this aspect of our proposal will strike many as controversial, but we think that it at least deserves serious consideration that such a decision, reached by a thorough, local democratic process, could enhance the autonomy of everyone in the community. For example, it seems that an advocate of Pettit's civic republican conception of autonomy should endorse this view.
Conclusion The original Nuffield Intervention Ladder implies that no policy can do more to promote liberty than non-intervention. Any action by the state, even the provision of information, imposes some cost to liberty. This is an inadequate representation of even Mill's classic liberalism. The other theories of liberty and autonomy reviewed above suggest several additional reasons why the assumptions structurally embodied in the one-sided ladder should be rejected. The balanced intervention ladder that we have proposed is a step towards a more adequate picture of the relationship between autonomy and public health action. We recognize, of course, that there are more values that should be recognized in public health policy deliberations than welfare and autonomy. An imperative to maximize absolute economic welfare, or to ensure that policy interventions increase equality, cannot be represented on the ‘ladder’. The fact that we have restricted ourselves here to examining the trade-off between just two values, welfare and autonomy, can be justified, we believe in the light of the central role that views about the structure of this trade-off play in current efforts to oppose effective action to promote public health.
Author statements Acknowledgements We would like to thank Pierrick Bourrat for comments on the draft and assistance with preparation of the manuscript.
Ethical approval None sought.
Funding None declared.
Competing interests None declared.
references
1. Nuffield Bioethics Council. Public health: ethical issues; 2007. 2. Dawson A, Verweij M. The Steward of the Millian state. Public Health Ethics 2008;1(3):193e5. 3. Mill JS. On liberty. London: John W. Parker and Son; 1859. 4. Mill JS. The subjection of women. London: Longmans, Green, Reader & Dyer; 1869. 5. Thaler RH, Sunstein CR. Nudge: improving decisions about health, wealth, and happiness. New Haven, CT: Yale University Press; 2008. 6. Barton A. How tobacco health warnings can foster autonomy. Public Health Ethics 2013;6(2):207e19. 7. Nolan D, West C. Liberalism and mental mediation. J Value Inq 2004;38:195e202. 8. Pettit P. Republicanism: a theory of freedom and government. Oxford: Oxford University Press; 1997. 9. Jennings B. Public health and liberty: beyond the Millian paradigm. Public Health Ethics 2009;2:123e34. 10. Nielsen MEJ. Republicanism as a paradigm for public health e some comments. Public Health Ethics 2011;4:40e52. 11. Powers M, Faden R, Saghai Y. Liberty, Mill and the framework of public health ethics. Public Health Ethics 2012;5:6e15. 12. Berlin I. Two concepts of liberty. In: Berlin I, editor. Four essays on liberty. London: Oxford University Press; 1969. p. 118e72. 13. Christman J. Autonomy in moral and political philosophy. In: Zalta EN, editor. The Stanford encyclopedia of philosophy. Available from: http://plato.stanford.edu/archives/spr2011/ entries/autonomy-moral/; Spring 2011. 14. Dworkin G. The theory and practice of autonomy. Cambridge: Cambridge University Press; 1988. 15. Frankfurt H. Freedom of the will and the concept of a person. In: Frankfurt H, editor. The importance of what we care about. Cambridge: Cambridge University Press; 1987. p. 11e25. 16. Benson P. Autonomy and oppressive socialization. Soc Theory Pract 1991;17(3):385e408. 17. Koorsgaard C. The sources of normativity. New York: Cambridge University Press; 1996. 18. Wolf S. Freedom and reason. New York: Oxford University Press; 1990. 19. Christman J. Autonomy and personal history. Can J Philos 1991;21(1):1e24. 20. Mackenzie C, Stoljar N, editors. Relational autonomy: feminist perspectives on autonomy, agency and the social self. New York: Oxford University Press; 2000. 21. Hastings G. The marketing matrix: how the corporation gets its power and how we can reclaim it. London: Routledge; 2012. 22. Hastings G. Public health and the value of disobedience. Public Health; 2015. Forthcoming. 23. Owens J, Cribb A. Beyond choice and individualism: understanding autonomy for public health ethics. Public Health Ethics 2013;6(3):262e71.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Mini-Symposium
A balanced intervention ladder: promoting autonomy through public health action P.E. Griffiths*, C. West Department of Philosophy, University of Sydney, NSW 2006, Australia
article info
abstract
Article history:
The widely cited Nuffield Council on Bioethics ‘Intervention Ladder’ structurally embodies
Received 16 November 2014
the assumption that personal autonomy is maximized by non-intervention. Consequently,
Received in revised form
the Intervention Ladder encourages an extreme ‘negative liberty’ view of autonomy. Yet
3 August 2015
there are several alternative accounts of autonomy that are both arguably superior as
Accepted 19 August 2015
accounts of autonomy and better suited to the issues facing public health ethics. We
Available online 29 August 2015
propose to replace the one-sided ladder, which has any intervention coming at a cost to autonomy, with a two-sided ‘Balanced Intervention Ladder,’ where intervention can either
Keywords:
enhance or diminish autonomy. We show that not only the alternative, richer accounts of
Nuffield council on bioethics
autonomy but even Mill's classic version of negative liberty puts some interventions on the
Intervention ladder
positive side of the ladder.
Public health ethics
Crown Copyright © 2015 Published by Elsevier Ltd on behalf of The Royal Society for Public
Nanny state
Health. All rights reserved.
John Stuart Mill
Public health ethics and the intervention ladder The 2007 Nuffield Council on Bioethics report Public health: ethical issues1 is a foundational document in the field of public health ethics. It was the subject of the opening editorial in the first issue of the journal Public Health Ethics2 and continues to be widely cited in that and cognate journals. Many of these authors take issue with elements of the report, as we do here, but it remains a key point of reference even for its critics. The Nuffield report developed a framework for justifying state interventions that cannot easily be justified within conventional liberal political theory because of John Stuart Mill's ‘harm principle’3: the state should not interfere with people's choices unless they cause harm to others. This principle can
be defended on both instrumentalist and intrinsic grounds. Instrumentally, Mill argued that individuals are the best judges of what is in their own interest. But he also suggested that the very purpose of our social institutions is, or should be, the promotion of individual liberty in the sense of reflective self-determination.3 So minimizing state interference is intrinsically desirable. The Nuffield report introduces an additional set of ethical considerations that need to be balanced against individual liberty. The ‘Stewardship model’ proposes that the state has a duty to enable its citizens to achieve good health. The report suggests that good stewardship will often conflict with the promotion of individual liberty. In that case, the cost to liberty needs to be balanced against the benefit to public health. The ‘intervention ladder’
* Corresponding author. Tel.: þ61 2 9351 7027. E-mail address: [email protected] (P.E. Griffiths). http://dx.doi.org/10.1016/j.puhe.2015.08.007 0033-3506/Crown Copyright © 2015 Published by Elsevier Ltd on behalf of The Royal Society for Public Health. All rights reserved.
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(Fig. 1) is a proposed framework for balancing these two considerations. There is much to admire in the Nuffield Council's report. However, many of the subtleties in the report are of necessity omitted from the intervention ladder. This matters, because the report is not intended merely for academic consumption. The intervention ladder is an important tool in communicating the report's conclusions to a wider audience, including policy makers. For example, the intervention ladder features prominently in an illustrated colour brochure Public health: ethical issues a guide to the report, issued alongside the main document and intended to summarize its conclusions. Our concern in this paper is with a structural feature of the ladder. The vertical axis of the ladder represents the increasing cost to liberty, and non-intervention is at the bottom. It is an immediate consequence of this structure that no policy can do more to promote liberty than non-intervention. Moreover, any action by the state, even the provision of information, imposes some cost to liberty. Subtler views can be found in the body of the report (see, for example, Sections 2.36 & 2.38), but this very unsubtle view is inescapably expressed in the main visual tool used to disseminate the report's findings.
Theories of freedom and autonomy The Intervention Ladder embodies a conception of freedom that can be termed negative, liberal, or libertarian and which
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equates autonomy with non-interference. On this conception, any intervention designed to promote public health necessarily comes at a cost to individual autonomy; and, consequently, stands in need of justification. This non-interference conception of autonomy means that the burden of proof is placed on public health advocates to demonstrate that the welfare benefits of any proposed intervention outweigh the costs to individual liberty. However, the philosophical literature offers numerous alternative accounts of autonomy. Many of these alternate accounts would not assume that public health initiatives automatically compromise autonomy. Interventions may sometimes enhance individual autonomy, and even sometimes be required for it. With these alternative accounts, we need not view public health interventions as necessarily posing a trade-off between freedom and other values (e.g. welfare). In this section and the next we provide a taxonomy of philosophical theories of freedom and autonomy, giving a sense of the place of the non-interference conception within this much wider territory. We argue that the traditional libertarian conception is impoverished; and go on to make a case for the superiority of a positive account of individual freedom or autonomy. Specifically, a better account of autonomy is provided by the positive accounts that include a reflective endorsement condition; we provide a discussion of what is meant by reflective endorsement. Such positive accounts of autonomy are compatible with the promotion of public health
Fig. 1 e The Intervention Ladder (numbers added by authors). ‘The range of options available to government and policy makers can be thought of as a ladder of interventions, with progressive steps from individual freedom and responsibility towards state intervention as one moves up the ladder. In considering which ‘rung’ is appropriate for a particular public health goal, the benefits to individuals and society should be weighed against the erosion of individual freedom. Economic costs and benefits would need be taken into account alongside health and societal benefits.’1
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measures; more strikingly still, an implication of these accounts is that some of the measures that restrict freedom on the libertarian model, actually enhance autonomy. In the latter part of this paper we propose a revised version of the ladder that incorporates this feature. The exact form of a revised ladder would, naturally, depend on what specific conception of autonomy is adopted. Our basic proposal, that the ladder requires a positive side to balance it, requires only a slightly more sophisticated version of negative liberty: as we will see shortly, the materials can be found in Mill's own account. The richer, alternative accounts of autonomy that we consider allow a wider range of actions to be identified as enhancing autonomy.
Freedom as non-interference: the libertarian conception The negative account of individual freedom finds its classic expression in John Stuart Mill's On Liberty. Mill is primarily concerned with self-determination: the ability to decide for yourself how to live your life. He writes, ‘[t]he only freedom which deserves the name is that of pursuing our own good in our own way, so long as we do not attempt to deprive others of theirs, or impede their efforts to obtain it.’3 An individual is free just so long as she is not prevented, by external or internal constraints, from acting on her desires. For Mill, external threats to freedom can take several forms: formal legal prohibitions and punishments, or informal social pressures to conform to established norms or sanctioned ways of life. Mill categorized the latter as ‘social coercion’, in contrast with legal coercion. In The Subjection of Women Mill displays sensitivity to the way in which individual autonomy can be compromised by the internalization of oppressive social norms that renders individuals ‘willing slaves’, invisibly bound to a mode of life that they would not choose under more idealdi.e. better factually informed, less restrictivedconditions.4 Mill famously insists that the only legitimate reason for coercive interference with individual liberty is in order to prevent harm to third parties. On Liberty begins with a wellknown statement of what has come to be known as the ‘harm principle’: ‘[T]he only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others.’3 Mill holds that neither the state nor any individual or smaller collective is ever justified in coercively interfering with a person's freedom simply for his or her own good. So far we see how these elements of Mill are consistent with the conception of autonomy embodied in the Intervention Ladder; yet Mill's position, in contrast to the Ladder, would not endorse the assumption of an automatic cost to liberty through the introduction of public health measures e for he takes intervention by so-called non-coercive means to be entirely consistent with individual liberty. Thus it is entirely legitimate to attempt to deter an individual from making ‘bad’ or imprudent choices by ‘remonstrating with him, or reasoning with him, or persuading him, or entreating him.’3 Consequently there is nothing in Mill's harm principle that assigns a cost in liberty to public education campaigns designed to inform or persuade consumers of the dangers of smoking or the merits of consuming more fruit and
vegetables; and, indeed, Mill asserts that a precondition for autonomous deliberation is foreknowledge of the likely consequences of one's choices and actions. Mill states explicitly that the harm principle is supposed to apply only to ‘human beings in the maturity of their faculties.’3 Thus even more paternalistic measures may be justified in dealings with children, and with adults whose decision-making capacities are temporarily or permanently impaired (e.g. through drunkenness, illness or mental incapacity); again with no cost to liberty. It would therefore be entirely consistent with the harm principle to, for instance, place restrictions on advertising directed at children in order to protect them from harming themselves. By placing the provision of information at one and regulation (including, presumably, restrictions on corporate marketing to children) at six, the Nuffield Ladder implies that such measures must come at a price to liberty. The only way to justify the assumption that the provision of information contingently comes at a cost to individual liberty is to further assume that people, as a matter of fact, do not want to be informed; but this assumption too appears unjustified. The provision of information should instead be represented as an intervention that enhances autonomy. The Nuffield Report proper recognizes these richer aspects of Mill's position (see, for example, Sections 2.36 & 2.38); yet the vision represented in the Nuffield Ladder is impoverished, neglecting these important aspects of Mill's account, as discussed above. The Ladder assumes that any intervention comes at a cost to liberty; Mill does not.
Nudging In an influential amendment to the libertarian position Cass Sunstein and Richard Thaler have defended a position they dub ‘libertarian paternalism,’ arguing that paternalistic ‘nudging’ is compatible with respect for libertarian freedom.5 ‘Nudging’ involves the deliberate attempt to steer individuals towards making choices that are likely to promote their own ends by fiddling with ‘choice architecture’ (the environment in which choices are made). The case for nudging starts from well-known behavioural research findings that undermine the factual presuppositions of Mill's instrumental argument against paternalism. Individuals are not rational actors who always act so as to maximize expected utility, but are prone systematically to make certain errors in pursuing their own good. One might worry that nudging is unjustifiably manipulative, since it depends on influencing individuals' choices in ways that individuals themselves are not consciously aware of and have not specifically consented to; but the foundation of Sunstein's argument is that our choices are inevitably influenced in some direction by the ‘choice environment’, and that we are commonly not conscious of this influence; the environment in which the citizen is free from all influence is a fiction; the only questions, then, are those concerning who influences our choices, how they do it, how aware are we of their intervention, and what are the ultimate effects of their influence. Moreover, it is plausible that, upon becoming informed about their own rational limitations, individuals would consent to ‘manipulation’ that serves their own desired goals, just as some individuals voluntary avail themselves of
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hypnotism and other subconscious mechanisms in attempts to give up smoking.6 In earlier work, one of us has argued that manipulation of this kind need not compromise autonomy if the individual gives consent to the process.7
Freedom as non-domination: the republican conception Philip Pettit has developed and defended an influential alternative negative conception of freedom. Pettit calls this the republican conception of freedom.8 The implications of this work for public health ethics have been explored by several authors.9e11 The libertarian or ‘neo-liberal’ conception contrasts freedom with constraint or interference, whereas on the republican conception the antonym of freedom is domination. Imagine a slave who is fortunate enough to have a benign mistress who lets him do whatever he wishes.8 This slave would be free on the liberal conception, since no one actually interferes with his choices, but he would be unfree on the republican conception, since he is a slave. More precisely, the fact that his mistress could interfere with his choices if she chose to, is sufficient to render him unfreedeven if she never actually interferes, and even if the probability that she will interfere is very low. Freedom, on Pettit's republican conception, equates to this kind of counterfactually robust or resilient non-interference. The republican conception of freedom remains a negative conception insofar as its chief focus remains on interference, but it differs from the libertarian or ‘neo-liberal’ account in implying that intervention need not be inimical to individual freedom, and may in fact be necessary for it. Without the protections afforded by a democratic constitution, for instance, individual members of a society cannot be free, no matter how much non-interference they happen to enjoy. In the context of this article, we note that the disproportionate power wielded by corporations to constrain and dictate the options available to ordinary consumers can be viewed as posing a very substantial threat to individual freedom, a threat from which individuals may have a freedom-based claim for protection. The example of the slave with the benign mistress is designed to show that (actual) non-interference is not sufficient for freedom. The interference of the sailors who bind Ulysses to the mast so as to enable him to resist the call of the Sirens is designed to show that non-interference is not necessary for freedom either. When the sailors bind Ulysses to the mast so as to enable him to resist the call of the Sirens, they constrain his actions, but not his freedom; for, in so binding him, they are acting in accordance with his expressed and considered wishes. Many of us are familiar with using less drastic devices of this kind to ‘bind’ ourselves into a desired pattern of healthy behaviour, whether by hiring a personal trainer or by the cheaper expedient of not buying the cookies we know we will want that evening.
Positive freedom and autonomy Negative neo-liberal and republican conceptions of freedom contrast with ‘positive’ conceptions, according to which freedom requires not merely the absence of constraints but
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also sufficient power and resourcesdmaterial, social and psychologicaldto pursue one's own ends effectively.12 Positive accounts of freedom regard non-interferencedeven resilient non-interferencedas insufficient; by these accounts, freedom requires skills and substantive opportunities that do not exist de novo, but must be enabled through education and other social goods. Autonomy is not something that individuals have by default, just so long as no one interferes with them. Making free and rational decisions about how to lead one's life, and then acting on them, requires information, imagination, critical reasoning abilities, literacy and numeracy skills and personal attributes (self-confidence, courage, forbearance, self-control), which can exist only with the appropriate social and institutional protections and supports. It also requires independence from internal and external sources of domination and control. Concern for individual autonomy may therefore justify interventions that foster these abilities and conditions.
Reflective endorsement The terms ‘freedom’ and ‘autonomy’ are sometimes used interchangeably; however, in many philosophical discussions, freedom is distinguished from autonomy in that the former is taken to concern constraints on an individual's ability to act on their desires, whereas autonomy concerns the independence and authenticity of an individual's desires (values, etc.) in the first place.13,14 Whereas the paradigm example of an unfree individual, in this sense, is someone who is physically restricted (e.g. imprisoned), the standard example of a non-autonomous individual is the addict who is compelled by her immediate desires to take drugs against her ‘better judgement’ (different theories of autonomy single out different psychological features as making choices genuinely autonomous). The autonomous individual, by contrast, is free from such internal, as well as external, domination. Thus distinguished, it is possible to be autonomous but unfree, and to be free but non-autonomous. Importantly, for our purposes, while processes such as brainwashing, manipulation, indoctrination and the internalization of oppressive norms may not pose a threat to freedom, so understood, they clearly pose a threat to autonomy. Thus, while the role of corporations and corporate marketing in shaping and manipulating individuals' desires may not be seen to pose a threat to (negative) freedom, it poses a prima facie threat to individual autonomy. Theories of autonomy in the philosophical literature agree that autonomy cannot be equated with an individual's ability to act on her (first-order) desires, because the desires (values, emotions, etc.) on which she acts may not be ones that she would endorse or want to act on, all things considered, upon the appropriate sort of critical reflection.14,15 To illustrate this point with an example: it may well be that if one of us were properly informed about the calorific and nutritional content of a delicious-looking chocolate cookie, they would no longer want to consume it, or would cease to judge consuming it to be in their best interests, given their strong desire to maintain a healthy weight. Under these circumstances, autonomy might be enhanced, rather than diminished, by interventions that assist them to resist the allure of the cookie, in accordance with their considered wishes. Such interventions might
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include their co-author ‘binding’ their choice by removing the cookies from the office. More seriously, considerations such as these might justify restrictions on the marketing and display of unhealthy foods in retail outlets to promote the autonomy of weak-willed consumers, given a suitable mandate from those consumers.
Procedural vs. substantive approaches In the philosophical literature on autonomy this reflective endorsement model is categorized as a procedural theory, in that it includes no restriction on the content of the desires (values, etc.) in virtue of which a person can be considered autonomous. In principle, any first-order desire that an agent would endorse by a process of critical reflection counts as autonomous in virtue of being so endorsed, regardless of the content of the desires. The majority of contemporary accounts of autonomy are procedural. Substantive theories of autonomy, by contrast, reject the claim that procedural independence is sufficient for autonomy; these accounts require, in addition, that autonomous preferences have specific contents or are formed under specific social conditions.16e18 For example, a substantive theory might insist that an individual (e.g. a willing junk food addict) who embraces his unhealthy lifestyle could not be genuinely autonomous, at least with respect to that lifestyle choice, as a matter of conceptual necessity, even if, upon reflection, he subjectively endorses this lifestyle and the processes that led him to embrace it. Substantive theories of autonomy are controversial because they tie the theory of autonomy to a particular view about what constitutes a valuable human life, and therefore conflict with the popular liberal commitment to value neutrality.
Structural, historical, and relational approaches Structural theories of autonomy focus on an aspect of the structure of a person's internal psychological state at a particular moment in time, and on whether the desires (values, etc.) on which a person acts have been subject to the appropriate sort of critical reflection, regardless of the external causal and historical processes that have led to this psychological state. Mill's negative account and the positive, reflective endorsement account discussed above are both structural theories of autonomy. Structural theories, both negative and positive, contrast with historical and relational theories of autonomy; the latter attend to broader external historical and social influences on deliberation and action, and the ways in which these influences may impede, or enhance, individual autonomy. (For examples of historical theories, see.19,14 For a classic discussion of relational approaches see.20) In so doing, they seek to address a wellknown problem with purely structural accounts by accounting for the apparently autonomy-compromising impact of processes such as brainwashing, indoctrination, manipulation and oppressive socialization. The science fiction example of the evil scientist, who secretly implants a device in a subject's brain so as to control their mental states paradigmatically deprives the subject of autonomy, not by interfering with their ability to act on their desires, but by controlling the
nature of their desires in the first place. This interference seems to violate autonomy even if the scientist interferes at the level of second order desires, such as the desire not to want to smoke. Structural approaches struggle to account for this intuition because they analyse autonomy as a feature of a person's mental state at a particular moment in time, ignoring the historical processes that may have led up to that psychological state. In the present context, historical and relational considerations might suggest that the ‘marketing matrix’21,22 plays much the same role as the hypothetical evil scientist.
A balanced intervention ladder The richer perspectives on autonomy that we have reviewed in this paper are well known in contemporary ethics and moral psychology, and have been discussed in public health ethics.6,23 If they are to have any influence on public discussion and on policy, however, they will need to be formulated in a manner as appealing as the original Intervention Ladder. This is readily done by a ‘balanced’ version of the ladder, in which inaction represents zero and actions may have either positive or negative consequences for freedom (Fig. 2). At the bottom of the ladder are public health actions that substantially restrict autonomy, and at the top are public health actions that substantially enhance autonomy. Comparing the original Ladder (Fig. 1) with our balanced ladder, the reader will see that some policy actions previously shown as diminishing autonomy are now on the positive side of the ladder. The discussion above has revealed that even on classical liberal principles, these actions enhance rather than diminish autonomy. This provides an even more urgent reason to replace the one-sided ladder. In the one-sided ladder, ‘nudge’ interventions were treated as moderate infringements of autonomy. In the balanced ladder they are treated as autonomy-neutral. This is perhaps the most controversial change we have made to the ranking in the original Ladder. However, we are persuaded by the argument (see above) that default choice architecture is not neutral. The shift from a choice architecture that subrationally manipulates consumers in a way that is indifferent to their interests to one in which some manipulations are designed to advance their interests is at worst autonomyneutral. The provision of information is treated in the original Ladder as a small infringement of autonomy. But it is uncontroversial that full information is a precondition of any genuinely autonomous choice. The balanced ladder therefore places the provision of accurate, relevant information on its first positive rung, as an autonomy-enhancing intervention. There may be other costs e financial ones, for example e to balance against the health benefits of this intervention, but there are no costs to autonomy. Classical liberalism itself recognizes the role of education in allowing individuals to develop their minds in ways that allow them able to participate as free and equal members of their society. Education equips individuals to understand their options, to weigh the costs and benefits of those options effectively, and perhaps to be more resistant to attempts at
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Fig. 2 e A balanced intervention ladder. The options available to government and policy makers to improve health may either enhance (þ) or diminish (¡) autonomy. No special justification is required for interventions that simultaneously enhance health and autonomy. For autonomy diminishing interventions, the health benefits to individuals and society should be weighed against this cost. In both cases, economic costs and benefits need be taken into account alongside health costs and benefits.
sub-rational manipulation. Education of this kind is on the second rung of the balanced intervention ladder as a substantially autonomy-enhancing intervention. While this change can be justified in terms of classical liberalism, relational and historical views of autonomy would regard this as a fundamental aspect of autonomy, and would take a broader view of what might count as educating for autonomy. For example they might emphasize the need to build the individual's sense of self-worth through education, as well as their ability to weigh costs and benefits. Some public health interventions seek to mandate or incentivise the provision of healthier options for people to choose between. Because these interventions add to the choices available to people without any compensating loss of choice, they cannot reasonably be regarded as reducing autonomy and, we place them on the third rung of the positive side of our ladder. These interventions do restrict corporations, but we should not conflate the freedom of corporations with the freedom of citizens. The ability of human beings to live as autonomous agents to the fullest extent possible may be a fundamental value, but the ability of a corporation to act autonomously can surely only be defended as an instrumental value. It may be that there are costs to economic efficiency
from interventions that make healthier choices available to consumers, and that may be an argument against intervening, but not because of the cost to autonomy, even on a classical liberal conception of autonomy! Most of us need help at some point in our lives to make the choices we want to make. We may hire a personal trainer, or join a structured program to quit smoking. A good way to look at such supports is as ‘scaffolding’ that allows us to act as an autonomous individual e someone whose goals and values are reflected in their actions. Interventions that provide scaffolding of this kind, which individuals can access to help them achieve their goals, are on the fourth rung of the balanced intervention ladder as very substantially autonomyenhancing interventions. This change to the ladder probably requires a conception of autonomy that at least includes the reflective endorsement condition that we argued for above. We tentatively consider a fifth and final rung on the positive side of the intervention ladder. This involves restricting the choices available to people, rather than facilitating choice. The kind of scaffolded autonomy that forms the fourth rung will often involve an individual removing certain options from their immediate grasp, as in the classical example of Ulysses and the Sirens. But what we have in mind here is a collective
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version of Ulysses. There are choices that cannot be effectively made except at the level of the community. In some cases, these policies represent trade-offs between the freedom of different individuals. Some people might prefer the freedom to play ear-splitting music in the small hours of the morning, but their neighbours have voted for a noise restriction to defend their freedom to sleep. But in other cases, the whole community may recognize through democratic decision-making that they wish to restrict their own choices in order to live, collectively, as they truly wish to live. The decision of a remote Australian community to ban the sale of alcohol as a means to deal with family violence might represent such an example. We recognize that this aspect of our proposal will strike many as controversial, but we think that it at least deserves serious consideration that such a decision, reached by a thorough, local democratic process, could enhance the autonomy of everyone in the community. For example, it seems that an advocate of Pettit's civic republican conception of autonomy should endorse this view.
Conclusion The original Nuffield Intervention Ladder implies that no policy can do more to promote liberty than non-intervention. Any action by the state, even the provision of information, imposes some cost to liberty. This is an inadequate representation of even Mill's classic liberalism. The other theories of liberty and autonomy reviewed above suggest several additional reasons why the assumptions structurally embodied in the one-sided ladder should be rejected. The balanced intervention ladder that we have proposed is a step towards a more adequate picture of the relationship between autonomy and public health action. We recognize, of course, that there are more values that should be recognized in public health policy deliberations than welfare and autonomy. An imperative to maximize absolute economic welfare, or to ensure that policy interventions increase equality, cannot be represented on the ‘ladder’. The fact that we have restricted ourselves here to examining the trade-off between just two values, welfare and autonomy, can be justified, we believe in the light of the central role that views about the structure of this trade-off play in current efforts to oppose effective action to promote public health.
Author statements Acknowledgements We would like to thank Pierrick Bourrat for comments on the draft and assistance with preparation of the manuscript.
Ethical approval None sought.
Funding None declared.
Competing interests None declared.
references
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