The Goals of Public Health An Integrated Multi-dimensional Model Christian Munthe Department of Philosophy, Göteborg University EuroPHEN, funded by the European Commission Final report:

Public health goals n Traditional goal u Promoting population health n Additional values/goals u Equality (focus on health inequalities, empowering the weak) u Autonomy (focus on health opportunities, respecting individual choice, and individual responsibility) n Conflicts & problems u Different views on population health and its value u Promoting equality may undermine population health u Promoting and/or respecting autonomy may undermine population health u Individual based vs. Population based perspectives on goals and practices u Consequences of the additional goals for PH practice unclear (monitoring, health promotion, safety management…) n Can the values/goals be integrated into a coherent and normatively plausible structure that is practically and politically feasible?

Population approach to autonomy? n Dead end: the autonomy of ‘the public’ u Aggregate of individual autonomy, the Public as an autonomous super-individual n Integration of equality and autonomy u Promote the equal and real opportunities of everyone to be more healthy (if they want to). Sweden, Netherlands, ?? u Focus on societal frameworks, public goods, empowerment, information, enabling and respecting choice, and individual responsibility u Freedom to make unhealthy choices may be restricted if they impede the equal opportunities of others to be more healthy (smoking in public places, safety restrictions, basic sanitation solutions etc.) u Differences to the traditional goal F Opportunities to be healthy rather than health F Prioritarian emphasis, equality rather than maximization F Only autonomy may trump autonomy n Differences too far-reaching ? u PH-practices and instruments made obsolete? u Communicable disease and other health emergencies u Negative health spirals u Underdeveloped societies u Why is it only important for society to provide health opportunities?

Integrating the traditional goal n Drawbacks of the integrated additional goal u Cannot plausibly replace the traditional goal (as in e.g. Sweden) u Rather, it assumes a good population health, although it may undermine this u Cannot explain why society should care more for health opportunities than for unhealth opportunities (although it says that this is the case) n The traditional goal thus seems to have a place, but… u There is some intuitive plausibility in the idea expressed by the integrated additional goal u Merely combining the integrated additional goal with the traditional goal is difficult, since they imply conflicting prescriptions n Solution: an integrated multi-dimensional goal structure u Each of the goals express a value-dimension (social utility, equality, autonomy) u The value-dimensions expressed by the different goals need to be integrated into one coherent model of the goals of PH u Such an integration have to involve some type of balancing of the relative moral importance of the different value-dimensions u Basic ways of balancing: F Lexical ordering (qualitative balancing relative to types) F Progressive increase (quantitative balancing relative to the level of population health) F Combination (my preferred choice)

A rough model (not a theory)  The more that population health is promoted, the less important it becomes to promote it further (and vice versa)  The more that population health is promoted, the more important it becomes that people may choose not to further promote their health (and vice versa)  The more that population health is promoted, the more important it becomes that the ability of people to choose to further promote their health is equally distributed (and vice versa)  Whether a PH measure is to be recommended depends on the balance of…  the magnitude to which the various goal-dimensions are promoted  their respective moral importance relative to actual population health  The exact size of the differences of moral importance, the exact relation of this size to level of population health, and the exact way to balance the importance against the magnitudes of the different goal-dimensions are left undecided

Application n (A) The lower the level of health of a population, the more reason to treat the traditional goal as paramount u Underdeveloped countries, areas, regions, etc. n (B) The higher the level of the health of the population, the more reason to treat the integrated additional goal as paramount u Create opportunities to further promote health, but allow people to sacrifice some additional health for other goods if they so prefer u Promote the situation of the worse-off although this may be ineffective in terms of population health u Block opportunities to sacrifice some additional health if these impede the equal opportunities to further promote health n If a situation of type B seriously threatens to deteriorate into a situation of type A due to the integrated additional goal being taken as paramount, the traditional goal becomes paramount u Negative spirals (unlikely) u Emergencies n There may be reasons to prioritize the traditional and the integrated additional goals differently in different sub-populations (multinational policy integration, e.g. EU) n There are good reasons to allocate PH resources to areas with lower levels of population health (e.g. Western Europe vs.central Africa), and in those areas the traditional goal will most often be paramount

Justification n Possibility and type of justification of a proposed goal depend on the ‘normative level’ of the goal u Final value u Contributory value u Instrumental value (based certain causal dependencies) n My hypothesis: a goal fitting the rough model can be justified by a broad range of minimally plausible normative ethical/political theories, but on different levels n From a philosophical perspective, the differences with regard to this are very interesting to explore! n From a practical public health perspective, however, it does not matter so much! n What matters for PH, though, is what such a goal broadly implies regarding u Allocation of resources u Choice of measures and target populations/areas u Monitoring focus and devices