The most typical ethical dilemma in public health ethics is that of state interference in choices concerning the health of people. According to the theory of negative liberty, it is of highest value that the state does not interfere with the freedom of people. People should be left alone.
However, from a positive concept of liberty and health—what Carter et al. denote as a capability point of view—interference could be justified. Peoples’ most important interest is probably not to be left alone, because ‘…they have a moral stake in that environment providing them with real opportunities, including the opportunity to be healthy’ .
Informing people through public health campaigns is one of the most classical ways of trying to help people taking good and healthy choices. There is nothing inherently unethical with information campaigns, if the information given is honest and correct. But one problem with them is that results are moderate, probably because education programmes have often failed to acknowledge the limitations of health education or the complex relationship between health communication and behaviour change, according to Gill and Boylan . In order to make them more effective, there is a temptation to move beyond factual and objective information and use instruments that make a strong appeal to emotions, like for instance the use of fear and disgust in anti-tobacco campaigns. While this may have a bigger effect than information, it also increases the risk of stigmatization. As Lupton claims, there is a substantial risk that such campaigns may ‘…reinforce negative attitudes towards already disadvantaged and marginalized individuals and social groups’ .
A less stigmatizing but maybe more coercive way of trying to improve public health is to tax products that contribute to poor health and disease, like tobacco, alcohol, sugar and fat. Such taxation might contribute to more ‘real opportunities’ for people to choose healthy, in the sense that unhealthy choices will not continue to be a cheap option. The coercive element here is that if you put really high taxes on some products, it will be too expensive for people to buy regularly.
An even more coercive strategy is to ban certain products or ban the use of certain products. Many countries today have a law on smoking, where smoking is banned in public buildings and transportation, restaurants, offices, etc. Systematic reviews suggest a considerable medical benefit from such legislation [11, 12]. There are many practical challenges with taxation of as well as a ban on certain products, such as equal treatment of different products and the risk of increased trade leakage to more liberal jurisdictions nearby. But deeper than that is the challenge that we cannot necessarily ban everything we may find unhealthy from our society. The characteristics of a liberal societies is that we allow people to choose the way they will live their lives, as long as this freedom of choice do not harm others, or significantly reduce others freedom of choice. This freedom of choice is regarded as an intrinsic value and as a common good in liberal democracies. A totalitarian regime could easily ban tobacco, Happy Meal, Toblerone and alcohol. But in liberal democracies, such laws would be considered a violation of some of our dearest values. This creates a tension between values. You have to carefully balance the two.
But how could laws against smoking in public indoor areas be introduced in liberal democracies if it violated fundamental liberal values? The answer is that these laws were introduced in the first place to safeguard the work environment. Nobody should be a victim of ‘passive smoking’. The justification of these laws was not that health trumped freedom of choice, but rather that the choice of smokers to smoke, threatened the freedom of choice of others (the choice of not smoking/not inhaling nicotine) in these buildings. In that sense, freedom of choice was the justification for banning the freedom to smoke indoors. The paradox, however, is that even though these laws were not motivated by health promotion, the consequences have probably been huge in terms of health.
Some scholars do, however, defend coercive strategies in a liberal democracy. Sarah Conley is one of them. People are generally prone to cognitive bias, says Conley. We make bad decisions because we are tempted, we lack will power and we have a bad means-end thinking. That makes it hard for us to reach our ultimate goals. Coercing people to do what is good for them is in this sense is respectful, because people then will reach their ultimate goals .
Is Conley’s position compatible with a health promotion view? On the one hand, health promotion is based on empowering and enabling people to realize their health potential. Coercion and prohibitions do not seem to have a place here. On the other hand, some types of addiction may be so hard to ignore and overcome that prohibitions (‘you are not allowed to smoke here’) actually could be the only thing that may help a person resist the craving for a cigarette. From such a perspective, law limiting and prohibiting smoking may help a person to get in control and in charge of his or her health. Although bans and prohibitions seldom would have a place within the paradigm of health promotion, we cannot absolutely rule out that such strategies may play a role in empowering and enabling people to live the lives that they really want to live.
Conley’s position, though, is challenging from a liberal perspective. As Jonathan Pugh has argued that it would be very problematic if it becomes impossible for agents to choose some action that poses a risk to their health without them being accused of making a cognitive error in weighing their values . Are all smokers today making a cognitive error when they choose to smoke? Could we ban smoking in general on the assumption that the ultimate goal of all smokers is to quit smoking? Probably the answer is no. People have different values and people weigh their values differently. That means that some smokers have no ultimate goal of quitting smoking. For them, coercive paternalism will become highly illiberal and not enabling them to live more in accordance with ultimate goals and values.