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

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.

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