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Slurs aside, let’s talk about the ethics of public health measures

Predictable positions followed the recent announcement of an increase in tobacco tax by 12.5% a year for four years. Public health advocates praised the tax, labelling those questioning it as “tobacco…

The recent tobacco tax rise showed the usual entrenched positions of public health advocates and libertarians. Nick|Allen/Flickr

Predictable positions followed the recent announcement of an increase in tobacco tax by 12.5% a year for four years.

Public health advocates praised the tax, labelling those questioning it as “tobacco industry apologists”. Libertarians, on the other hand, decried it as further evidence of the “nanny state” and The Australian’s Adam Creighton went as far as to compare the measure to Nazis.

Apart from incensing readers, the noise from these well-worn positions drowns out significant public health concerns. The uncritical acceptance from public health and knee-jerk rejection from libertarians leaves little room to ask whether increasing the tobacco tax is unquestionably good.

It’s time for a new conversation.

Public health and liberal ideals

In liberal societies, we like to use economic and scientific knowledge in the belief that they allow for governance that’s morally neutral.

But many commentators note that the attempt to remain neutral on questions of morality and the public good has contributed to disappointment with liberal democracy. Focus groups are used to write public policy; opinion polls determine elections; and public spaces and institutions are privatised.

These transformations demotivate citizens from action and erode the civic sense of commonality and mutuality. The problems we face seem too big (obesity or climate change), the avenues for engagement too narrow (voting or twitter) and we are no longer sure who “we” means.

Public health is suffering from similar problems. Economics and science have greatly benefited public health and enabled us to say “smoking isn’t immoral but it does damage health and impose financial costs”. But they have also tended to hide the ethically significant features of public health interventions.

Prominent public health professor Simon Chapman has argued that we shouldn’t confuse health and morality but this is not always possible.

The difficulty of disentangling health and morality is evident in debates about obesity and smoking. Using the body mass index to define a fat person as diseased isn’t merely a scientific description.

Telling a smoker that they impose costs on the health-care system isn’t simply an economic statement. These descriptions carry within them normative judgements about the ideal way of living in society.

Public health, like liberal democracy, needs to make explicit the ethical basis and ideals behind its activity.

Moving beyond liberalism

Ethicist Angus Dawson argues that the liberal tradition provides an inadequate foundation for public health ethics.

The primacy given to liberty and non-interference in liberalism locks us into intractable debates about the importance of the individual versus the population. To escape this deadlock we appeal to economic and scientific discourses rather than engage in explicitly ethical discussions.

Dawson and others working in public health ethics, suggest a plurality of ethical theories specific to public health are needed. Liberal ideas of freedom and harm have been very useful in clinical ethics, where the focus is on individuals.

But in public health, we need an explicit conversation about the ethical basis of interventions into the lives of individuals, communities and society.

The tobacco tax is not morally neutral or wholly good, and it may have a disproportionate effect on the vulnerable among us. Mental health advocate John Mendoza has argued that it would have a big impact on people with mental illness, for instance.

Are the moral obligations of public health to maximise welfare, pursue social justice or addressing health inequalities? And what weight should we give to different ethical principles of reciprocity, solidarity, utility, liberty, equity and responsibility?

By addressing these questions we engage more fully with the tobacco tax rise than the just distribution of tax revenue. We can also question the moral status of smoking and whether smoking can be part of a good society.

Such conversations will not end in a consensus, but they will help articulate the points of difference and contention. This will help us move beyond the usual slurs – “nannies”, “Nazis” or “industry apologists” – to identify the ethical and political concerns at the heart of the debate.

By engaging in a more open discussion about the ethical basis of public health interventions and taxes, not only will neglected issues get a hearing but the vitriol and rhetoric may also get turned down a little.

Join the conversation

19 Comments sorted by

  1. James Jenkin

    EFL Teacher Trainer

    It's true we should discuss the ethical basis of interventions.

    This also means discussing when it is right not to act, as well as to act.

    Intervention by experts can help us; however, it can also lessen our autonomy, sense of responsibility, and critical faculties.

    But I agree, let's ditch the 'nanny state' cliches.

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    1. Judith Olney

      Ms

      In reply to James Jenkin

      Agree James, and I did see some people actually discussing the ethical basis of intervention in Patrick Stokes recent article on this same issue. Although, we did also see the predictable responses as well.

      IMO smokers, like asylum seekers, single parents, welfare recipients, (apart from those deemed deserving), among others, are the scapegoats of society, and this comes about as a result of state sanctioned discrimination, dehumanisation and denigration. I believe it is also a case of cowardice…

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    2. David Thompson

      Marketing Research

      In reply to James Jenkin

      And we would be fools not to listen to the 'experts' advice within the context of their own self-interests.

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    3. electivecesarean.com

      logged in via Twitter

      In reply to Judith Olney

      Judith, I'm trying to make contact with you regarding your comment about breech birth in another article. Would you mind getting in touch please? Thanks!

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  2. David Thompson

    Marketing Research

    Actually Adam Creighton's more important point was that Rudd's claims about "$31 billion cost" was based on the flimsiest and most egregious abuse of cost-benefit analysis that I, at least, have ever seen.

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    1. David Thompson

      Marketing Research

      In reply to David Thompson

      Having said that, I still support Rudd's policy.

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    2. Bron Larner

      Retired Humantities

      In reply to David Thompson

      A brilliant analysis and critique of deliberately misleading anti-smoking statistics peddled by the Government and the Health Industry has been written by Emeritus Professor Peter Derrick Finch, Foundation Professor of Statistics at Monash University, and is available on the Web. I think, if Professor Peter Finch is an Emeritus Professor of statistics, he might actually know what he is talking about. See: Foundation Professor and Emeritus Professor of Statistics at Monash University; Department of Mathematics, Peter Derrick FINCH, BA, Durh., Professor of Mathematical Statistics (1 July 1964 - 31 December 1994)

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  3. Sean Lamb

    Science Denier

    The tax hike is generally approved only by a group of miserly self-satisified middle-class tightwads,who are too mean to pay for the things they expect from government by way of a tax hike that would hit their hip pockets and prefer a an additional slug on the addicted who they delusionally assert are a drain on the public purse. That these same middle-class tightwads will probably live to average age of 93 and cost far more than the unfortunate smokers is a fact that apparently is too complex to…

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  4. Tom Hennessy

    Retired

    "public health measures"

    Refusing vaccinations is being called, a public health risk , but , hepatitis carriers are allowed to walk freely amongst us ?

    "Transmission of hepatitis B virus by sweating/ perspiration"
    "Tears from children with chronic hepatitis B virus (HBV) infection are infectious vehicles of HBV transmission"

    Hepatitis infected health care workers are allowed, as long as its not an
    'exposure prone procedure' , which I cannot fully understand , since they pass it by sweating.

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  5. margot cullen

    carer

    simply ....smoking is legal...go forth and destroy oneself....its your choice. no amount of taxing or ugling packaging is going to STOP smoking.so lets make it even simpler by making it illegal if you really/honestly want to save lives. this will mean shutting down xxx manufacturers and eventually will include growers of tobacco. imagine the side effects of doing this...of course we are talking about everything from mass unemployment to significant loss of gov revenue and it goes on. its got nothing to do about ethics...its all about the $. less than 1.5% of the health dollar is spent on prevention..the rest is spent on treatment.....imagine even if we spent at least half on preventing illness....sure the side effects wouls not be seen in our lifetime but is this not ethical thinking for the future human beings.

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  6. rory robertson

    logged in via email @gmail.com

    Thanks for your thought-provoking piece, Dr Mayes. Here's a question for you and your readers involving ethics in science and public health. For starters, it is clear that:

    (a) modern rates of sugar consumption - especially via sugary drinks - are a key driver of global obesity and type 2 diabetes, together the greatest public-health challenge of our times: http://care.diabetesjournals.org/content/33/11/2477.full.pdf and http://www.abc.net.au/catalyst/stories/3821440.htm

    (b) in particular…

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    1. Judith Olney

      Ms

      In reply to rory robertson

      Rory, did you see the ABC program 'Catalyst' last night?

      Excellent coverage of this subject, with Robert Lustig and Gary Taubes.

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    2. rory robertson

      logged in via email @gmail.com

      In reply to Judith Olney

      Yes indeedy, Judith. Obviously, it suited what readers know is my strong bias - sugar is a menace to public health - just by correctly presenting the facts of the matter: http://www.abc.net.au/catalyst/stories/3821440.htm

      Readers, one of the bonuses that flowed from that program was that TheConversation's old mate David Driscoll spent the rest of the night beside himself. Taubes annoys him. Lustig annoys him. And there they both were, telling the truth. If his nemesis David Gillespie had come…

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    3. Judith Olney

      Ms

      In reply to rory robertson

      Hi Rory, I haven't read much of what David Driscoll has to say, not interested.

      I have read Gillespie and Taube's books, and seen several interviews with Lustig, I have also looked at studies conducted elsewhere, including the study you have posted several times on this website, and have made up my own mind.

      I limit sugar as much as possible in my diet, and do not consume sugary drinks. I also avoid artificial sweeteners. I have found a vast improvement in my own health by doing this.

      We will not see the government health officials tackle obesity or alcohol with any conviction, because of cowardice, and the fact that the majority of people, (read voters), are overweight and drink alcohol, (many to excess).

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    4. rory robertson

      logged in via email @gmail.com

      In reply to Judith Olney

      Judith, I agree with much of that, but I think you might be a bit strong with your use of the word "cowardice". My understanding is that the National Health and Medical Research Council and other public-health officials stood up strongly against the University of Sydney and other food-and-beverage-industry interests in "The Great Sugar Fight of 2012": http://www.smh.com.au/national/health/research-causes-stir-over-sugars-role-in-obesity-20120330-1w3e5.html

      While it seems that the NHMRC's planned toughening of official dietary advice against sugar was delayed from 2012 until 2013, it still happened. So I applaud the officials at the NHMRC who were involved, and others too, including Dr Rosemary Stanton and Professor Amanda Lee: http://www.australianparadox.com/pdf/canberradietary.pdf ; http://www.abc.net.au/lateline/content/2013/s3693188.htm

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    5. Judith Olney

      Ms

      In reply to rory robertson

      I use the word cowardice very deliberately, particularly in regards to the cowardly behaviour of politicians. They are interested in buying the votes of the majority, and sanctioning the vilification of minority groups , while at the same time preventing measures that have been shown to improve health, and work as public health policy, so they can reap the financial gains from people's addictions.

      If the government was serious about public health, in regards to people quitting smoking, then they would be using all money collected from cigarette taxes, to fund ways to help people quit.

      Instead we have the opposite.

      E cigarettes have been mentioned by others on this site, so I did a little digging, and the government opposition to e cigs in Australia is a great example of the above cowardice and greed.

      I can't help but be cynical Rory, when the facts are what they are.

      http://www.ecigalternative.com/ecigarette-studies-research.htm

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    6. rory robertson

      logged in via email @gmail.com

      In reply to Judith Olney

      I get your point, Judith. I'll nevertheless put your word "cowardice" to one side. The word I've settled on in my dispute with the University of Sydney is "disingenuous". To recap, I have documented the fact that senior scientists have negligently misread the available data in their high-profile Australian Paradox paper, mistaking up for down while embracing a data series that was discontinued as unreliable and then falsified: Sections 1-10 in www.australianparadox.com

      Such obvious problems…

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  7. Arkarbor

    logged in via Twitter

    Just wondering if anyone has more current figures?
    * Of the total health care costs resulting from all forms of drug abuse in 1998-99, approximately 80% were attributable to tobacco. In that year costs attributable to tobacco were $1094.4 million net, including medical, hospital, nursing home and pharmaceutical costs (Collins and Lapsley 2002).
    ( http://www.abs.gov.au/ausstats/abs@.nsf/mf/4831.0.55.001 )

    * Revenue from tobacco taxes in Australia (1999) $1,341.1 million net
    ( http://www.tobaccoinaustralia.org.au/chapter-13-taxation/13-6-revenue-from-tobacco-taxes-in-australia )

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