1. The Goals of Public Health and the Ethics of Public Health Policy Christian Munthe Department of Philosophy, Göteborg University EuroPHEN, financed by the European Commission.

2. Traditional Goal, Restrictions & Problems n Goals u Promotion of the health of the population F Aggregate of the health status of individuals F Life-expectancy, mortality, morbidity, well-being F Focus on socio-economic policy as a means F What aggregate? (utilitarian, communitarian, weighing goods) F What population? (national vs. european vs. global) n Restrictions u Efficiency u Cost-benefit u Liberty/autonomy to a limited extent n Public Health vs. Medical Ethics u Population perspective vs. Individualist perspective (Doctor - patient relationship) u Respect for autonomy

3. Recent Trends n Equality u Focus on health inequalities u Empowerment of “weak” groups u Prioritarianism rather than strict egalitarianism (?) u Opportunities rather than actual health states u Conflict 1: poor uptake, inefficiency (traditional goal) u Conflict 2: unhealthy choices in spite of health opportunities n Autonomy u Focus on opportunity, access, information, empowerment u Focus on respecting choice ==> individual responsibility u Conflict 1 (surface): individual freedom vs. common good u Conflict 2 (deeper): individualist vs. population approach

4. A Population Approach to Autonomy(?) n The Autonomy ‘of the Population’ u Aggregate of individual autonomy (of what? How? Quantifiability?) u Strong communitarianism ==> organic theory of society ==> conflict with traditional goal more severe n Marriage of Equality and Autonomy u The equal opportunity of each member of the population to (autonomously) choose good/better health u Netherlands, Sweden, ?? u Promote the existence of real options for everyone to be more healthy (if they want to) u Focus on public goods, empowerment, information and choice u Particular individuals’ freedom to make unhealthy choices may be restricted (smoking in public places, restricting the content of X in food, etc.) u Restriction on the traditional goal F Prioritarianist emphasis F Only autonomy may trump autonomy

5. Justification and Application n Libertarian egalitarianism (moral claim) u Autonomy and equality are the primary values u Levelling down problem ==> traditional goal must play a part n Priority of Liberty (Rawls) u When a sufficient level of health is secured for everyone, ability to control one’s own health level becomes a priority (moral/psychological claim) n Utilitarianism (empirical claims) u The better off people are, the more they care about autonomy and equality u When a certain level of well being is secured, the connection between health and well being becomes more complex (Mill’s principle of first person priority + priority of liberty apply) u Suboptimal outcomes acceptable if they contribute to an optimal body of policies n Consequentialist prioritarianism u Increasing the well being of the worse off is more important (moral claim) u The utilitarian empirical claims n Applications to policy making u Expansion less appropriate, the worse the socio-economic setting u Threats to basic public goods justify retreat to traditional goal u Different goals appropriate in different social settings, nations, etc.